Provider Demographics
NPI:1245391721
Name:BAUTISTA, ROSA E (MSW)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:E
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1108
Mailing Address - Country:US
Mailing Address - Phone:914-965-3700
Mailing Address - Fax:914-997-4972
Practice Address - Street 1:19 GREENRIDGE AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1201
Practice Address - Country:US
Practice Address - Phone:914-949-7680
Practice Address - Fax:914-997-4972
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052760101YM0800X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355940OtherAGENCY MEDICAID PROVIDER ID
NY1285628552OtherAGENCY NPI #
NYWVE061OtherAGENCY MEDICARE ID#