Provider Demographics
NPI:1225703275
Name:BAUTISTA, KENNETH (RBT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25350 MAGIC MOUNTAIN PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6320 CANOGA AVE FL 15
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-2563
Practice Address - Country:US
Practice Address - Phone:661-214-3063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-21-178540106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician