Provider Demographics
NPI:1982440400
Name:BRAVO MIND PSYCHIATRY PLLC
Entity type:Organization
Organization Name:BRAVO MIND PSYCHIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:VILLASENOR
Authorized Official - Last Name:NARDINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-201-2656
Mailing Address - Street 1:13423 BLANCO RD UNIT 3164
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2187
Mailing Address - Country:US
Mailing Address - Phone:210-201-2656
Mailing Address - Fax:
Practice Address - Street 1:4405 7TH AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1055
Practice Address - Country:US
Practice Address - Phone:210-201-2656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-03
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health