MEDICARE: DR. KARINA S BRAVO PH.D., LMFT

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	46928	CA

General Provider Information

NPI Number	:	1912022252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KARINA S BRAVO PH.D., LMFT

Provider Business Mailing Address
First Line	:	5500 UNIVERSITY PKWY
Second Line	:	C/O PSYCHOLOGY DEPARTMENT
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-2318
Country	:	US
Telephone Number	:	909-537-5947
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 UNIVERSITY PKWY
Second Line	:	C/O PSYCHOLOGY DEPARTMENT
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-2318
Country	:	US
Telephone Number	:	909-537-5947
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	09/16/2010

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