Provider Demographics
NPI:1699558940
Name:BRAVO COBIAN, ANITA
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:BRAVO COBIAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2148 ASHFORD DR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4469
Mailing Address - Country:US
Mailing Address - Phone:575-935-1177
Mailing Address - Fax:
Practice Address - Street 1:2148 ASHFORD DR
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4469
Practice Address - Country:US
Practice Address - Phone:575-935-1177
Practice Address - Fax:575-935-1178
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSAH-2025-0030235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist