Provider Demographics
NPI:1538598289
Name:BAUTISTA, ROSANNA
Entity type:Individual
Prefix:
First Name:ROSANNA
Middle Name:
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 1:3034 KINGSBRIDGE AVE APT 2CS
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-5147
Mailing Address - Country:US
Mailing Address - Phone:917-689-0072
Mailing Address - Fax:
Practice Address - Street 1:3034 KINGSBRIDGE AVE APT 2CS
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5147
Practice Address - Country:US
Practice Address - Phone:917-689-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY1378866202103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No174400000XOther Service ProvidersSpecialist