Healthcare Provider Details

I. General information

NPI: 1922519701
Provider Name (Legal Business Name): ALEXANDRA BRAVO DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA MONIQUE BRAVO

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 08/18/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 N MOUNTAIN AVE
UPLAND CA
91786-4167
US

IV. Provider business mailing address

818 N MOUNTAIN AVE
UPLAND CA
91786-4167
US

V. Phone/Fax

Practice location:
  • Phone: 415-992-6155
  • Fax: 650-360-6913
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number96620
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number96620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: