Healthcare Provider Details

I. General information

NPI: 1053959403
Provider Name (Legal Business Name): YESSENIA VIVIANA BAUTISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 TECHNOLOGY CT STE 105
RIVERSIDE CA
92507-2181
US

IV. Provider business mailing address

612 S MYRTLE AVE STE 100
MONROVIA CA
91016-3406
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number123126
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: