Provider Demographics
NPI:1720385222
Name:BECERRA-BAUTISTA, VANESSA B
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:B
Last Name:BECERRA-BAUTISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5485 DUNGAREE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-2089
Mailing Address - Country:US
Mailing Address - Phone:702-883-0722
Mailing Address - Fax:
Practice Address - Street 1:9550 S EASTERN AVE STE 253
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-8042
Practice Address - Country:US
Practice Address - Phone:702-883-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
NVCP5538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner