Provider Demographics
NPI:1619073756
Name:BEVILACQUA, STACEY M (LMHC, CASAC, MA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:LMHC, CASAC, MA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:HASSETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC, CASAC, MA
Mailing Address - Street 1:6099 NEW TAYLOR RD
Mailing Address - Street 2:RIGHT SIDE
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-316-4990
Mailing Address - Fax:
Practice Address - Street 1:6099 NEW TAYLOR RD
Practice Address - Street 2:RIGHT SIDE
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2385
Practice Address - Country:US
Practice Address - Phone:716-800-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22894101YA0400X
NY004210-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)