Provider Demographics
NPI:1902475973
Name:BRAVO PSYCHOLOGICAL GROUP, LLC
Entity Type:Organization
Organization Name:BRAVO PSYCHOLOGICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:301-233-5020
Mailing Address - Street 1:656 QUINCE ORCHARD RD STE 600
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1418
Mailing Address - Country:US
Mailing Address - Phone:301-233-5020
Mailing Address - Fax:
Practice Address - Street 1:656 QUINCE ORCHARD RD STE 600
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1418
Practice Address - Country:US
Practice Address - Phone:301-233-5020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty