Provider Demographics
NPI:1053508713
Name:BEVILACQUA-HARDING, MARIANNE
Entity Type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:
Last Name:BEVILACQUA-HARDING
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 1:1774 GENTRY LN
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-2059
Mailing Address - Country:US
Mailing Address - Phone:484-883-0919
Mailing Address - Fax:
Practice Address - Street 1:1774 GENTRY LN
Practice Address - Street 2:
Practice Address - City:STATHAM
Practice Address - State:GA
Practice Address - Zip Code:30666-2059
Practice Address - Country:US
Practice Address - Phone:484-883-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC006148L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020403110001OtherPROMISE PROVIDER ID#