Provider Demographics
NPI:1194297630
Name:BAUTISTA, ROSE M (LCSW)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MDG
Mailing Address - Street 2:UNIT 5115
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:48 MDG
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09461
Practice Address - Country:US
Practice Address - Phone:575-769-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1803138104100000X
NMSWB-2022-04051041C0700X
NM104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical