Healthcare Provider Details

I. General information

NPI: 1275720096
Provider Name (Legal Business Name): VERONICA BRAVO GAVIN MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 ARLINGTON AVE STE B
RIVERSIDE CA
92504-1966
US

IV. Provider business mailing address

44759 CORTE GUTIERREZ
TEMECULA CA
92592-1164
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-4964
  • Fax:
Mailing address:
  • Phone: 951-303-1937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 47022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: