Provider Demographics
NPI:1093231433
Name:BAUTISTA, EZEQUIEL (MT-BC, NMT)
Entity type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MT-BC, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 N 3RD STREET
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2702 N 3RD STREET
Practice Address - Street 2:SUITE 1000
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004
Practice Address - Country:US
Practice Address - Phone:602-840-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist