Provider Demographics
NPI:1316769136
Name:BRAVO, PAMELA (LCSW-C)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 FLINT HILL RD
Mailing Address - Street 2:
Mailing Address - City:ADAMSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21710-9212
Mailing Address - Country:US
Mailing Address - Phone:240-507-6069
Mailing Address - Fax:
Practice Address - Street 1:2919 FLINT HILL RD
Practice Address - Street 2:
Practice Address - City:ADAMSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21710-9212
Practice Address - Country:US
Practice Address - Phone:240-507-6069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MD234381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health