Provider Demographics
NPI:1518203140
Name:BAUTISTA, SUZANNE R (NCACII, CADACII)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:R
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:NCACII, CADACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-6906
Mailing Address - Country:US
Mailing Address - Phone:317-240-2801
Mailing Address - Fax:317-240-2807
Practice Address - Street 1:5230 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-6906
Practice Address - Country:US
Practice Address - Phone:317-240-2801
Practice Address - Fax:317-240-2807
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0973101YA0400X
171M00000X, 171R00000X, 174H00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171R00000XOther Service ProvidersInterpreter
No174H00000XOther Service ProvidersHealth Educator
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)