Provider Demographics
NPI:1164192712
Name:BEVACQUA, CASEY LYNN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:CASEY
Middle Name:LYNN
Last Name:BEVACQUA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107B N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-2371
Mailing Address - Country:US
Mailing Address - Phone:908-272-3400
Mailing Address - Fax:
Practice Address - Street 1:107B N UNION AVE
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-2371
Practice Address - Country:US
Practice Address - Phone:908-272-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01096900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist