Provider Demographics
NPI:1366056277
Name:BAUTISTA, LESLIE NAIN
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:NAIN
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 1:410 TARROW ST STE 102
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-7892
Mailing Address - Country:US
Mailing Address - Phone:979-721-6062
Mailing Address - Fax:
Practice Address - Street 1:410 TARROW ST STE 102
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-7892
Practice Address - Country:US
Practice Address - Phone:979-721-6062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39688103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist