Provider Demographics
NPI:1659984409
Name:BAUTISTA, KIMBERLY (MSED)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E 119TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-4433
Mailing Address - Country:US
Mailing Address - Phone:917-691-6222
Mailing Address - Fax:
Practice Address - Street 1:535 E 119TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-4433
Practice Address - Country:US
Practice Address - Phone:917-691-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-30
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency