Provider Demographics
NPI:1093251001
Name:BAUTISTA, BERTHA ALICIA (LMFT)
Entity type:Individual
Prefix:
First Name:BERTHA ALICIA
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 CALEB CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-2306
Mailing Address - Country:US
Mailing Address - Phone:619-622-5261
Mailing Address - Fax:
Practice Address - Street 1:5555 RESERVOIR DR STE 309
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5193
Practice Address - Country:US
Practice Address - Phone:619-622-5261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127869106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist