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General NPI Number Information
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NPI Number | 1225703275
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Entity Type | Individual
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Provider Name | KENNETH BAUTISTA RBT
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Gender | Male
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Dates
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Enumeration Date | 08/11/2021
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Last Update Date | 08/11/2021
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Provider Practice Location Address
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Address Line | 6320 CANOGA AVE FL 15
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City | WOODLAND HILLS
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State | CA
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Zip | 91367-2563
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Country | US
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Telephone | 661-214-3063
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Fax |
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Provider Business Mailing Address
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Address Line | 25350 MAGIC MOUNTAIN PKWY STE 300
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City | SANTA CLARITA
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State | CA
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Zip | 91355-1356
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-21-178540
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License Number State | CA
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