Provider Demographics
NPI:1922825744
Name:VILLALBAZO BRAVO, FER
Entity type:Individual
Prefix:
First Name:FER
Middle Name:
Last Name:VILLALBAZO BRAVO
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:FERNANDA
Other - Last Name:VILLALBAZO BRAVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1465 30TH ST STE K
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3497
Mailing Address - Country:US
Mailing Address - Phone:619-428-1000
Mailing Address - Fax:
Practice Address - Street 1:1465 30TH ST STE K
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3497
Practice Address - Country:US
Practice Address - Phone:619-428-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health