Healthcare Provider Details

I. General information

NPI: 1245167295
Provider Name (Legal Business Name): STEPHANIE BRAVO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S FAIRFIELD AVE # 5-13
CHICAGO IL
60608-1782
US

IV. Provider business mailing address

1501 S CALIFORNIA AVE # 7-140
CHICAGO IL
60608-1732
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-4068
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.031739
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: