MEDICARE: ODALISKA BAUTISTA

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1366808255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ODALISKA BAUTISTA

Provider Business Mailing Address
First Line	:	175 MIDDLE ST UNIT 1201
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3625
Country	:	US
Telephone Number	:	407-915-7714
Fax Number	:	866-610-0580

Provider Business Practice Location Address
First Line	:	11476 S APOPKA VINELAND RD STE 118
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32836-7006
Country	:	US
Telephone Number	:	407-955-4001
Fax Number	:	407-745-0738

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

Provider Enumeration Date	:	01/07/2016
Last Update Date	:	07/21/2022

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Directions to “ ODALISKA BAUTISTA ” Practice Location

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