Healthcare Provider Details

I. General information

NPI: 1194297630
Provider Name (Legal Business Name): ROSE M BAUTISTA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MDG UNIT 5115
APO AE
09461
US

IV. Provider business mailing address

48 MDG UNIT 5115
APO AE
09461
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2345
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1803138
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2022-0405
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: