Provider Demographics
NPI:1437571304
Name:BEVILACQUA, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
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:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-2526
Mailing Address - Country:US
Mailing Address - Phone:575-751-7552
Mailing Address - Fax:
Practice Address - Street 1:413 SIPAPU ST
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6489
Practice Address - Country:US
Practice Address - Phone:575-751-7552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator