Provider Demographics
NPI:1710694450
Name:MARTIN-BAUTISTA, SANTA SELENA (SUDPT)
Entity Type:Individual
Prefix:
First Name:SANTA
Middle Name:SELENA
Last Name:MARTIN-BAUTISTA
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 59
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532
Mailing Address - Country:US
Mailing Address - Phone:360-740-4380
Mailing Address - Fax:360-740-1877
Practice Address - Street 1:506 W. FRANKLIN STREET
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3517
Practice Address - Country:US
Practice Address - Phone:360-427-5232
Practice Address - Fax:360-427-5006
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61358497101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor