MEDICARE: DORKA M BAUTISTA B.A., M.A.

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1750837308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DORKA M BAUTISTA B.A., M.A.

Provider Business Mailing Address
First Line	:	3010 GRAND CONCOURSE
Second Line	:	APT. 3K
City	:	BRONX
State	:	NY
Zip	:	10458-1511
Country	:	US
Telephone Number	:	646-639-8829
Fax Number	:

Provider Business Practice Location Address
First Line	:	3010 GRAND CONCOURSE
Second Line	:	APT. 3K
City	:	BRONX
State	:	NY
Zip	:	10458-1511
Country	:	US
Telephone Number	:	646-639-8829
Fax Number	:

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

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	09/01/2016

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