Provider Demographics
NPI:1992000293
Name:BEVILACQUA, KRISTIN E (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:E
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:E
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:SC HOUSE CALLS INC.
Mailing Address - Street 2:111 DOCTORS CIR.
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:800-491-0909
Mailing Address - Fax:843-589-1585
Practice Address - Street 1:SC HOUSE CALLS INC.
Practice Address - Street 2:111 DOCTORS CIR.
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:800-491-0909
Practice Address - Fax:843-589-1585
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH3758Medicaid
SCGP9145Medicaid