Provider Demographics
NPI:1346441250
Name:BAUTISTA, MICHELLE MARTHA (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARTHA
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 12454
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-0454
Mailing Address - Country:US
Mailing Address - Phone:773-480-3412
Mailing Address - Fax:
Practice Address - Street 1:917 W 18TH ST STE 219
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2400
Practice Address - Country:US
Practice Address - Phone:773-480-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0119521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical