Provider Demographics
NPI:1558409532
Name:BEVACQUA, RICHARD (LCSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BEVACQUA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 BARK ST
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-1866
Mailing Address - Country:US
Mailing Address - Phone:732-255-4014
Mailing Address - Fax:
Practice Address - Street 1:PREFERRED BEHAVIORAL HEALTH SAIL PROGRAM
Practice Address - Street 2:999 AIRPORT ROAD
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:732-367-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC008363001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8382603Medicaid
NJ526788Medicare ID - Type UnspecifiedPBH GROUP #