Provider Demographics
NPI:1639783624
Name:BAUTISTA, LYZA ANGELICA
Entity Type:Individual
Prefix:
First Name:LYZA ANGELICA
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 1:30 KOELE WAY APT C
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-5729
Mailing Address - Country:US
Mailing Address - Phone:808-777-0746
Mailing Address - Fax:
Practice Address - Street 1:500 ALA MOANA BLVD STE 400
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-4920
Practice Address - Country:US
Practice Address - Phone:808-472-6522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician