Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRAVEMAN, L.M.F.T., D.S.T.
Provider Other First Name:
STEPHEN
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.M.F.T., D.S.T.
Provider Other Last Name Type Code:
2