Provider Demographics
NPI:1003166380
Name:BAUTISTA, MARY-JO (MA)
Entity Type:Individual
Prefix:
First Name:MARY-JO
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13715 VIA DEL PALMA AVE
Mailing Address - Street 2:APT G
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90602-2325
Mailing Address - Country:US
Mailing Address - Phone:808-292-5693
Mailing Address - Fax:
Practice Address - Street 1:13715 VIA DEL PALMA AVE
Practice Address - Street 2:APT G
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-2325
Practice Address - Country:US
Practice Address - Phone:808-292-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 28789103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical