Provider Demographics
NPI:1033800560
Name:BAUTISTA, MONIQUE (LCSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5036 SNOWBERRY DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-0759
Mailing Address - Country:US
Mailing Address - Phone:323-480-3177
Mailing Address - Fax:
Practice Address - Street 1:6101 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-5362
Practice Address - Country:US
Practice Address - Phone:909-202-8361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1152891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical