Provider Demographics
NPI:1649757535
Name:HERNANDEZ BAUTISTA, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:HERNANDEZ 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 1:1301 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3124
Mailing Address - Country:US
Mailing Address - Phone:562-595-1159
Mailing Address - Fax:
Practice Address - Street 1:222 W 6TH ST STE 230
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3332
Practice Address - Country:US
Practice Address - Phone:310-833-3135
Practice Address - Fax:310-707-2877
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW90551101YM0800X, 101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker