Provider Demographics
NPI:1104175389
Name:BAUTISTA, LETICIA
Entity type:Individual
Prefix:MISS
First Name:LETICIA
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41650 MAROON TOWN DR
Mailing Address - Street 2:APT C
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-1151
Mailing Address - Country:US
Mailing Address - Phone:760-550-7441
Mailing Address - Fax:
Practice Address - Street 1:47825 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6950
Practice Address - Country:US
Practice Address - Phone:760-863-8455
Practice Address - Fax:760-863-8587
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator