Provider Demographics
NPI:1619358439
Name:BEVACQUA, MATTHEW ALEXANDER (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:BEVACQUA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 E WADSWORTH PARK DR STE 230
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8096
Mailing Address - Country:US
Mailing Address - Phone:385-308-8034
Mailing Address - Fax:
Practice Address - Street 1:65 E WADSWORTH PARK DR STE 230
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8096
Practice Address - Country:US
Practice Address - Phone:385-308-8034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT03402225100000X
MEPT5966225100000X
CT13136225100000X
MA25535225100000X
NY047378225100000X
DEJ1-0014396225100000X
NJ40QA02019100225100000X
MI5501301792225100000X
DCPT200001236225100000X
MD25503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist