Provider Demographics
NPI:1598034464
Name:BRAVO, ERIC WARD (PSYD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:WARD
Last Name:BRAVO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 WINTER WALK DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-7808
Mailing Address - Country:US
Mailing Address - Phone:301-233-5020
Mailing Address - Fax:
Practice Address - Street 1:4 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3407
Practice Address - Country:US
Practice Address - Phone:301-740-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05013103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical