Provider Demographics
NPI:1467931527
Name:BRAVO, ACACIA MARIE (CSWA/QMHP-R)
Entity type:Individual
Prefix:
First Name:ACACIA
Middle Name:MARIE
Last Name:BRAVO
Suffix:
Gender:F
Credentials:CSWA/QMHP-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA14480104100000X
OR23-QMHP-R-2224101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500823659Medicaid