Healthcare Provider Details

I. General information

NPI: 1225293871
Provider Name (Legal Business Name): LUIS DANNY BAUTISTA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date: 07/10/2020
Reactivation Date: 10/05/2021

III. Provider practice location address

3850 CRENSHAW BLVD
LOS ANGELES CA
90008-1821
US

IV. Provider business mailing address

503 OCEAN FRONT WALK
VENICE CA
90291-2403
US

V. Phone/Fax

Practice location:
  • Phone: 323-593-5300
  • Fax:
Mailing address:
  • Phone: 310-392-3070
  • Fax: 310-452-8766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: