Provider Demographics
NPI:1962762260
Name:BAUTISTA, MARY GRACE A (PT)
Entity type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:A
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 S FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11782 SW BARNES RD STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5933
Practice Address - Country:US
Practice Address - Phone:503-906-4323
Practice Address - Fax:503-906-4319
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPT63986225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist