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General NPI Number Information
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NPI Number | 1366902504
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Entity Type | Individual
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Provider Name | NICOLE LEANN BRAVO B.S, MFT TRAINEE
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Gender | Female
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Dates
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Enumeration Date | 03/22/2019
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Last Update Date | 06/29/2021
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Provider Practice Location Address
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Address Line | 2716 OCEAN PARK BLVD STE 3075
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City | SANTA MONICA
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State | CA
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Zip | 90405-5232
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Country | US
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Telephone | 310-612-2998
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Fax |
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Provider Business Mailing Address
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Address Line | 1630 ACACIA AVE
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City | TORRANCE
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State | CA
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Zip | 90501-3114
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Country | US
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Telephone | 310-561-5545
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 122703
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License Number State | CA
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