Provider Demographics
NPI:1336926195
Name:BEVILACQUA, NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 MAIN ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-2127
Mailing Address - Country:US
Mailing Address - Phone:631-896-5721
Mailing Address - Fax:
Practice Address - Street 1:99 MAIN ST
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-3109
Practice Address - Country:US
Practice Address - Phone:845-540-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118448104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker