Healthcare Provider Details

I. General information

NPI: 1649788167
Provider Name (Legal Business Name): LESLIE BAUTISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6809 INDIANA AVE # 130-B26
RIVERSIDE CA
92506-4221
US

IV. Provider business mailing address

6809 INDIANA AVE # 130-B26
RIVERSIDE CA
92506-4221
US

V. Phone/Fax

Practice location:
  • Phone: 951-382-4842
  • Fax:
Mailing address:
  • Phone: 951-382-4842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: