Provider Demographics
NPI:1801083639
Name:BAUTISTA, LEONARD RALPH (MPT)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:RALPH
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 W 214TH ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-1924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:295 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-3141
Practice Address - Country:US
Practice Address - Phone:562-435-1699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 32007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist