=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811798564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAIA BRAVO RCSWI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2025
-----------------------------------------------------
Last Update Date | 03/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22904 LYDEN DR UNIT 104
-----------------------------------------------------
City | ESTERO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33928-7048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-494-3951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16048 HERONS VIEW DR
-----------------------------------------------------
City | ALVA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33920-4650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-882-0646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | ISW18360
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------