Provider Demographics
NPI:1164519138
Name:BEVACQUA, CHRISTINE ELIZABETH (PT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:ELIZABETH
Last Name:BEVACQUA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-3143
Mailing Address - Country:US
Mailing Address - Phone:732-578-9297
Mailing Address - Fax:
Practice Address - Street 1:1279 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-3323
Practice Address - Country:US
Practice Address - Phone:732-255-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00640400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist