Healthcare Provider Details

I. General information

NPI: 1750939864
Provider Name (Legal Business Name): BRAVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2019
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 FORUM BLVD STE C-2
COLUMBIA MO
65203-5436
US

IV. Provider business mailing address

203 JOHNSON CT
ASHLAND MO
65010-9473
US

V. Phone/Fax

Practice location:
  • Phone: 573-862-6992
  • Fax:
Mailing address:
  • Phone: 573-862-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELIZABETH HOCKER
Title or Position: OWNER
Credential: LPC
Phone: 573-823-6992