Provider Demographics
NPI:1871043943
Name:BAUTISTA-AVILA, IRASEMA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:IRASEMA
Middle Name:
Last Name:BAUTISTA-AVILA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:IRASEMA
Other - Middle Name:
Other - Last Name:AVILA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 1895
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78599-1895
Mailing Address - Country:US
Mailing Address - Phone:956-406-7020
Mailing Address - Fax:
Practice Address - Street 1:231 AMBER DR
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-8589
Practice Address - Country:US
Practice Address - Phone:956-406-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110855104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110855OtherTEXAS BEHAVIORAL HEALTH EXECUTIVE COUNCIL