Provider Demographics
NPI:1821603325
Name:BEVACQUA, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BEVACQUA
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 1:6823 FARNSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-4514
Mailing Address - Country:US
Mailing Address - Phone:216-644-2344
Mailing Address - Fax:
Practice Address - Street 1:6823 FARNSWORTH DR
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-4514
Practice Address - Country:US
Practice Address - Phone:216-644-2344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
OH175848101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty