Provider Demographics
NPI:1477373108
Name:BAUTISTA, MICHAEL ADRIAN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ADRIAN
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 1:417 S MAY ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60436-2040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11914 ILLINOIS ROUTE 59
Practice Address - Street 2:UNIT 134
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585
Practice Address - Country:US
Practice Address - Phone:630-381-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-348053106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician