MEDICARE: BRAVE WELLNESS STUDIO

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1639837974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAVE WELLNESS STUDIO

Provider Business Mailing Address
First Line	:	6020 SANTO RD STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-1195
Country	:	US
Telephone Number	:	858-737-4674
Fax Number	:

Provider Business Practice Location Address
First Line	:	6020 SANTO RD STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-1195
Country	:	US
Telephone Number	:	858-737-4674
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DENISE ALBA
Credential	:	LMFT
Telephone Number	:	858-737-4674

Provider Enumeration Date	:	12/03/2021
Last Update Date	:	12/03/2021

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Directions to “BRAVE WELLNESS STUDIO ” Practice Location

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