MEDICARE: BRAVE NORTH THERAPY, LCSW, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1285422881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAVE NORTH THERAPY, LCSW, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 1241
Second Line	:
City	:	WEEDSPORT
State	:	NY
Zip	:	13166-1241
Country	:	US
Telephone Number	:	315-834-2014
Fax Number	:

Provider Business Practice Location Address
First Line	:	2211 STATE ROUTE 31
Second Line	:
City	:	PORT BYRON
State	:	NY
Zip	:	13140-9420
Country	:	US
Telephone Number	:	315-834-2014
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KIMBERLY FORTIN
Credential	:	LCSW-R
Telephone Number	:	315-834-2014

Provider Enumeration Date	:	04/25/2025
Last Update Date	:	01/08/2026

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