Provider Demographics
NPI:1295273019
Name:BEVILACQUA, LAURA (MFTI)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 GUTHRIE LN # B
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-4059
Mailing Address - Country:US
Mailing Address - Phone:925-222-9657
Mailing Address - Fax:
Practice Address - Street 1:160 GUTHRIE LN # B
Practice Address - Street 2:SUITE 1
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-4059
Practice Address - Country:US
Practice Address - Phone:925-222-9657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74986106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist