MEDICARE: MRS. MARY JO BRAVO-GIANCOLA OT/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	003816	OH

General Provider Information

NPI Number	:	1720487333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY JO BRAVO-GIANCOLA OT/L

Provider Business Mailing Address
First Line	:	3500 WOODRIDGE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1534
Country	:	US
Telephone Number	:	216-337-8120
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 WOODRIDGE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1534
Country	:	US
Telephone Number	:	216-337-8120
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2014
Last Update Date	:	08/19/2014

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