Provider Demographics
NPI:1174204572
Name:BAUTISTA CEJA, VANESSA LISETTE
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:LISETTE
Last Name:BAUTISTA CEJA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:LISETTE
Other - Last Name:BAUTISTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2600 REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2325
Mailing Address - Country:US
Mailing Address - Phone:562-256-2900
Mailing Address - Fax:
Practice Address - Street 1:2600 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2325
Practice Address - Country:US
Practice Address - Phone:562-599-9280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117915101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health