Provider Demographics
NPI:1700245552
Name:MIRANDA BRAVO, MARIA LORETO
Entity type:Individual
Prefix:MS
First Name:MARIA
Middle Name:LORETO
Last Name:MIRANDA BRAVO
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 1:1111 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5505
Mailing Address - Country:US
Mailing Address - Phone:410-837-2050
Mailing Address - Fax:410-752-1374
Practice Address - Street 1:5500 KNOLL NORTH DR
Practice Address - Street 2:370
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2370
Practice Address - Country:US
Practice Address - Phone:410-837-2050
Practice Address - Fax:410-234-8177
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6787101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional