Provider Demographics
NPI:1063836104
Name:BAUTISTA, KATHLEEN ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ELIZABETH
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:PO BOX 19248
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9248
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:100 STAHLHUT DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-5059
Practice Address - Country:US
Practice Address - Phone:217-735-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149164281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical