MEDICARE: VERONICA BAUTISTA LCSW

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	1041C0700X	Clinical Social Worker	118045	CA

General Provider Information

NPI Number	:	1588436901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VERONICA BAUTISTA LCSW

Provider Business Mailing Address
First Line	:	2314 E MARKET ST
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95205-5635
Country	:	US
Telephone Number	:	209-423-0680
Fax Number	:

Provider Business Practice Location Address
First Line	:	221 TUXEDO CT STE A
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95204-5261
Country	:	US
Telephone Number	:	209-423-0680
Fax Number	:

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

Provider Enumeration Date	:	10/30/2023
Last Update Date	:	10/30/2023

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