Provider Demographics
NPI:1265165799
Name:BAUTISTA, STEPHANIE GUADALUPE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GUADALUPE
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 1:7916 LA RIVIERA DR APT 284
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-1684
Mailing Address - Country:US
Mailing Address - Phone:209-226-3714
Mailing Address - Fax:
Practice Address - Street 1:5301 F ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3226
Practice Address - Country:US
Practice Address - Phone:916-999-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist