Provider Demographics
NPI:1245065895
Name:BAUTISTA, CORTNEY DAWN (MS, LAC)
Entity type:Individual
Prefix:MRS
First Name:CORTNEY
Middle Name:DAWN
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 HUALAPAI MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-8324
Mailing Address - Country:US
Mailing Address - Phone:928-753-9387
Mailing Address - Fax:
Practice Address - Street 1:2215 HUALAPAI MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-8324
Practice Address - Country:US
Practice Address - Phone:928-753-9387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-20765101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health