Healthcare Provider Details

I. General information

NPI: 1245975630
Provider Name (Legal Business Name): BRAVO PSYCHOLOGICAL GROUP LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2022
Last Update Date: 05/01/2022
Certification Date: 05/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 QUINCE ORCHARD RD
GAITHERSBURG MD
20878-1409
US

IV. Provider business mailing address

656 QUINCE ORCHARD RD
GAITHERSBURG MD
20878-1409
US

V. Phone/Fax

Practice location:
  • Phone: 301-233-5020
  • Fax:
Mailing address:
  • Phone: 301-233-5020
  • Fax: 240-912-9564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIC W BRAVO
Title or Position: PSYCHOLOGIST
Credential: PSY.D.
Phone: 301-233-5020