Provider Demographics
NPI:1407446578
Name:BAUTISTA, GENESIS (BA)
Entity Type:Individual
Prefix:
First Name:GENESIS
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PARK ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703
Mailing Address - Country:US
Mailing Address - Phone:508-222-7525
Mailing Address - Fax:
Practice Address - Street 1:140 PARK ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703
Practice Address - Country:US
Practice Address - Phone:508-222-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker