Provider Demographics
NPI:1346673233
Name:BAUTISTA, VIRGINIA
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 W FLAMINGO RD STE 107
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-0165
Mailing Address - Country:US
Mailing Address - Phone:702-489-3331
Mailing Address - Fax:702-924-0628
Practice Address - Street 1:5580 W FLAMINGO RD STE 107
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-0165
Practice Address - Country:US
Practice Address - Phone:702-489-3331
Practice Address - Fax:702-924-0628
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10671-M101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst