Provider Demographics
NPI:1518540152
Name:BAUTISTA, DIVINE GRACE MENDOZA
Entity type:Individual
Prefix:MS
First Name:DIVINE GRACE
Middle Name:MENDOZA
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 MIRIAM ST
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-1952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:374 MIRIAM ST
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94014-1952
Practice Address - Country:US
Practice Address - Phone:415-580-9146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician