Provider Demographics
NPI:1578988416
Name:BAUTISTA, LENNY MANUEL
Entity Type:Individual
Prefix:
First Name:LENNY
Middle Name:MANUEL
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WHITTIER ST
Mailing Address - Street 2:APT 6
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3108
Mailing Address - Country:US
Mailing Address - Phone:857-869-0722
Mailing Address - Fax:
Practice Address - Street 1:3815 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3745
Practice Address - Country:US
Practice Address - Phone:617-983-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-02
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical