Provider Demographics
NPI:1275840597
Name:BAUTISTA, JUAN
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:
Last Name:BAUTISTA
Suffix:
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 1:7314 MIRAMONTE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-2540
Mailing Address - Country:US
Mailing Address - Phone:323-589-9043
Mailing Address - Fax:
Practice Address - Street 1:3605 LONG BEACH BLVD STE 331
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4025
Practice Address - Country:US
Practice Address - Phone:562-989-0537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor