Provider Demographics
NPI:1184200214
Name:BEVILACQUA, VALERIE
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:BEVILACQUA
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 1:630 FAIRVIEW RD STE 202
Mailing Address - Street 2:
Mailing Address - City:SWARTHMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19081-2335
Mailing Address - Country:US
Mailing Address - Phone:610-990-4232
Mailing Address - Fax:
Practice Address - Street 1:630 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:SWARTHMORE
Practice Address - State:PA
Practice Address - Zip Code:19081-2334
Practice Address - Country:US
Practice Address - Phone:610-990-4232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA120530831001OtherKEYSTONE HEALTH PLAN EAST