=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578045720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAVAS COUNSELING SERVICES-LCSW, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2018
-----------------------------------------------------
Last Update Date | 09/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 ROUTE 9
-----------------------------------------------------
City | FISHKILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12524-2560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-243-7024
-----------------------------------------------------
Fax | 845-440-0036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 792
-----------------------------------------------------
City | WAPPINGERS FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12590-0792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-590-8224
-----------------------------------------------------
Fax | 845-440-0036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | TAMEIKA L HINTON
-----------------------------------------------------
Credential | LCSW-R, BC-TMH
-----------------------------------------------------
Telephone | 845-590-8224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R075523
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------