Healthcare Provider Details

I. General information

NPI: 1144133398
Provider Name (Legal Business Name): THEA LORRIZE BAUTISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13980 BLOSSOM HILL RD STE A
LOS GATOS CA
95032-5121
US

IV. Provider business mailing address

4098 CHERRY AVE
SAN JOSE CA
95118-1715
US

V. Phone/Fax

Practice location:
  • Phone: 619-795-9925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: