Provider Demographics
NPI:1487179347
Name:BAUTISTA, KATHY AMIESYS
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:AMIESYS
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 1:10722 OLD SYCAMORE LOOP
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-4988
Mailing Address - Country:US
Mailing Address - Phone:781-584-9081
Mailing Address - Fax:
Practice Address - Street 1:131 JOHNSON ST APT 6
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-4030
Practice Address - Country:US
Practice Address - Phone:781-584-9081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
RBT-18-50861106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA452807522OtherPASSPORT