Provider Demographics
NPI:1811778079
Name:BRAVO ALKADDUMI, MIRANDA ELIZABETH
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELIZABETH
Last Name:BRAVO ALKADDUMI
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 1:1435 BEGONIA WAY
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8643
Mailing Address - Country:US
Mailing Address - Phone:951-204-7275
Mailing Address - Fax:
Practice Address - Street 1:1435 BEGONIA WAY
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-8643
Practice Address - Country:US
Practice Address - Phone:951-204-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220154480103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool