Provider Demographics
NPI:1457400863
Name:BRAVO, VANESSA I (MS SLP CCC)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:I
Last Name:BRAVO
Suffix:
Gender:F
Credentials:MS SLP CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12224 SHADY FOREST DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5632
Mailing Address - Country:US
Mailing Address - Phone:813-671-0807
Mailing Address - Fax:
Practice Address - Street 1:12224 SHADY FOREST DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5632
Practice Address - Country:US
Practice Address - Phone:813-671-0807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA372235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL356413OtherWELLCARE
FLS1374OtherBCBS
FL887664900Medicaid