=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871397463
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAVEE BEHAVIORAL HOLISTIC HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2025
-----------------------------------------------------
Last Update Date | 04/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 LONG TRAIL TER
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-7766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-704-4002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 LONG TRAIL TER
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-7766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-546-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BEHAVIOR HEALTH DIRETOR
-----------------------------------------------------
Name | DR. REGINA JOHNSON
-----------------------------------------------------
Credential | LGADC
-----------------------------------------------------
Telephone | 240-704-4002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------