Basic Information
| Provider Information | |||||||||
| NPI: | 1194173799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIFFITH | ||||||||
| FirstName: | AIENA LAYA | ||||||||
| MiddleName: | ANGELES BAUTISTA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAUTISTA | ||||||||
| OtherFirstName: | AIENA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 120 WILLIAM PENN PLZ | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 WILLIAM PENN PLZ | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2016 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 19703 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P20142 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P20142 | 01 | NC | STATE LICENSE | OTHER |