Provider Demographics
NPI:1295068971
Name:BAUTISTA, GERARD
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 E. GRAVES AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3414
Mailing Address - Country:US
Mailing Address - Phone:626-280-6510
Mailing Address - Fax:626-288-8903
Practice Address - Street 1:7600 E. GRAVES AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-3414
Practice Address - Country:US
Practice Address - Phone:626-280-6510
Practice Address - Fax:626-288-8903
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF64319106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist