Healthcare Provider Details

I. General information

NPI: 1578514964
Provider Name (Legal Business Name): KRIS BEVILACQUA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 WAVERLY AVE
BROOKLYN NY
11238-1706
US

IV. Provider business mailing address

382 WAVERLY AVE
BROOKLYN NY
11238-1706
US

V. Phone/Fax

Practice location:
  • Phone: 917-822-3946
  • Fax:
Mailing address:
  • Phone: 917-822-3946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number013798-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: