Provider Demographics
NPI:1225293871
Name:BAUTISTA, LUIS DANNY JR
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:DANNY
Last Name:BAUTISTA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 OCEAN FRONT WALK
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2403
Mailing Address - Country:US
Mailing Address - Phone:310-392-3070
Mailing Address - Fax:310-452-8766
Practice Address - Street 1:503 OCEAN FRONT WALK
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2403
Practice Address - Country:US
Practice Address - Phone:310-392-3070
Practice Address - Fax:310-452-8766
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2023-09-21
Deactivation Date:2020-07-10
Deactivation Code:
Reactivation Date:2021-10-05
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)