Provider Demographics
NPI:1538562749
Name:BRAVO, CARISSA D (PSYD)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:D
Last Name:BRAVO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:CARISSA
Other - Middle Name:D
Other - Last Name:SCALF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-734-3430
Mailing Address - Fax:541-734-3638
Practice Address - Street 1:70 BOWER DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3689
Practice Address - Country:US
Practice Address - Phone:541-734-3430
Practice Address - Fax:541-734-3638
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR3008103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health