Provider Demographics
NPI:1396419859
Name:BEVACQUA, LARISSA LAIS (OTR/L)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:LAIS
Last Name:BEVACQUA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:LAIS
Other - Last Name:LAURINDO LOPES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12501 PROSPERITY DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1689
Mailing Address - Country:US
Mailing Address - Phone:301-777-2000
Mailing Address - Fax:301-241-0124
Practice Address - Street 1:12501 PROSPERITY DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1689
Practice Address - Country:US
Practice Address - Phone:301-777-2000
Practice Address - Fax:301-241-0124
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09336225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist