Provider Demographics
NPI:1720602881
Name:BAUTISTA, DEANNA NICOLE (BCBA)
Entity Type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:NICOLE
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
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Mailing Address - Street 1:18726 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3813
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:855-568-0800
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1250
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4633
Practice Address - Country:US
Practice Address - Phone:714-656-0354
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA12042397103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst