Healthcare Provider Details

I. General information

NPI: 1518203140
Provider Name (Legal Business Name): SUZANNE R. BAUTISTA NCACII, CADACII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 12/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 W 10TH ST
INDIANAPOLIS IN
46224-6906
US

IV. Provider business mailing address

5230 W 10TH ST
INDIANAPOLIS IN
46224-6906
US

V. Phone/Fax

Practice location:
  • Phone: 317-240-2801
  • Fax: 317-240-2807
Mailing address:
  • Phone: 317-240-2801
  • Fax: 317-240-2807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0973
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: