Provider Demographics
NPI:1881936680
Name:BAUTISTA, MINDA (MPT)
Entity type:Individual
Prefix:MRS
First Name:MINDA
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 TIMOTHY LANE
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016
Mailing Address - Country:US
Mailing Address - Phone:773-877-8370
Mailing Address - Fax:
Practice Address - Street 1:759 TIMOTHY LN
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1155
Practice Address - Country:US
Practice Address - Phone:773-877-8370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist