Provider Demographics
NPI:1396558854
Name:BAUTISTA, LISSETTE (MA)
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-5816
Mailing Address - Country:US
Mailing Address - Phone:973-337-9317
Mailing Address - Fax:
Practice Address - Street 1:1187 MAIN AVE STE 3F
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2252
Practice Address - Country:US
Practice Address - Phone:855-453-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00853300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health