Provider Demographics
NPI:1518371012
Name:BAUTISTA, EDITH (PT-ASSISTANT)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:PT-ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 CHIHUAHUA ST STE 2
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043-3658
Mailing Address - Country:US
Mailing Address - Phone:956-568-4571
Mailing Address - Fax:
Practice Address - Street 1:2108 CHIHUAHUA ST STE 2
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78043-3658
Practice Address - Country:US
Practice Address - Phone:956-568-4571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2051137225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant