Healthcare Provider Details

I. General information

NPI: 1437571304
Provider Name (Legal Business Name): LEAH BEVILACQUA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 PASEO DEL PUEBLO SUR STE C
TAOS NM
87571-6023
US

IV. Provider business mailing address

PO BOX 11
EL PRADO NM
87529-0011
US

V. Phone/Fax

Practice location:
  • Phone: 575-224-2232
  • Fax:
Mailing address:
  • Phone: 575-751-7552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: