Healthcare Provider Details

I. General information

NPI: 1104257500
Provider Name (Legal Business Name): MONICA MISHELLE BAUTISTA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16580 HARBOR BLVD STE O
FOUNTAIN VALLEY CA
92708-1396
US

IV. Provider business mailing address

16580 HARBOR BLVD STE O
FOUNTAIN VALLEY CA
92708-1396
US

V. Phone/Fax

Practice location:
  • Phone: 949-250-0488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number109949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: