Provider Demographics
NPI:1063196749
Name:BAUTISTA, KENELEY (MS)
Entity type:Individual
Prefix:MRS
First Name:KENELEY
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 S COLLEGE ST APT L
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18102-5791
Mailing Address - Country:US
Mailing Address - Phone:610-400-9365
Mailing Address - Fax:
Practice Address - Street 1:134 BROAD ST STE 2
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-1590
Practice Address - Country:US
Practice Address - Phone:570-856-4232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional