Provider Demographics
NPI:1396311957
Name:BRAVO, YURITZY MARIE
Entity type:Individual
Prefix:
First Name:YURITZY
Middle Name:MARIE
Last Name:BRAVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2327
Mailing Address - Street 2:
Mailing Address - City:AVALON
Mailing Address - State:CA
Mailing Address - Zip Code:90704-2327
Mailing Address - Country:US
Mailing Address - Phone:562-704-2468
Mailing Address - Fax:
Practice Address - Street 1:320 METROPOLE AVE
Practice Address - Street 2:
Practice Address - City:AVALON
Practice Address - State:CA
Practice Address - Zip Code:90704-2863
Practice Address - Country:US
Practice Address - Phone:562-704-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YS0200X, 103TC2200X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent