Healthcare Provider Details

I. General information

NPI: 1396558854
Provider Name (Legal Business Name): LISSETTE BAUTISTA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1187 MAIN AVE STE 3F
CLIFTON NJ
07011-2252
US

IV. Provider business mailing address

159 N 17TH ST
BLOOMFIELD NJ
07003-5816
US

V. Phone/Fax

Practice location:
  • Phone: 855-453-6611
  • Fax:
Mailing address:
  • Phone: 973-337-9317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00853300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: