MEDICARE: MRS. CORTNEY DAWN BAUTISTA MS, LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LAC-20765	AZ

General Provider Information

NPI Number	:	1245065895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CORTNEY DAWN BAUTISTA MS, LAC

Provider Business Mailing Address
First Line	:	2215 HUALAPAI MOUNTAIN RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-8324
Country	:	US
Telephone Number	:	928-753-9387
Fax Number	:

Provider Business Practice Location Address
First Line	:	2215 HUALAPAI MOUNTAIN RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-8324
Country	:	US
Telephone Number	:	928-753-9387
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2024
Last Update Date	:	09/04/2024

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