MEDICARE: MRS. LISA BRAVO MC, LPC, LISAC

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	101YP2500X	Professional Counselor	LPC12442	AZ

General Provider Information

NPI Number	:	1851521017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA BRAVO MC, LPC, LISAC

Provider Business Mailing Address
First Line	:	1490 S PRICE RD
Second Line	:	SUITE 110
City	:	CHANDLER
State	:	AZ
Zip	:	85286-6607
Country	:	US
Telephone Number	:	480-540-5193
Fax Number	:

Provider Business Practice Location Address
First Line	:	1490 S PRICE RD
Second Line	:	SUITE 110
City	:	CHANDLER
State	:	AZ
Zip	:	85286-6607
Country	:	US
Telephone Number	:	480-540-5193
Fax Number	:

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

Provider Enumeration Date	:	07/22/2009
Last Update Date	:	07/22/2009

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