Provider Demographics
NPI:1447375217
Name:BAUTISTA, KIM SAIAZAR (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:SAIAZAR
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:SAIAZAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7 WALLINGFORD RISE
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450
Mailing Address - Country:US
Mailing Address - Phone:315-946-5722
Mailing Address - Fax:
Practice Address - Street 1:1519 NYE ROAD
Practice Address - Street 2:WAYNE BEHAVIORAL HEALTH NETWORK
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489
Practice Address - Country:US
Practice Address - Phone:315-946-5722
Practice Address - Fax:315-946-7066
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0732991104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker