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General NPI Number Information
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NPI Number | 1619073756
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Entity Type | Individual
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Provider Name | STACEY M BEVILACQUA LMHC, CASAC, MA
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Gender | Female
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 03/22/2023
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Provider Practice Location Address
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Address Line | 6099 NEW TAYLOR RD RIGHT SIDE
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City | ORCHARD PARK
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State | NY
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Zip | 14127-2385
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Country | US
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Telephone | 716-800-1766
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Fax |
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Provider Business Mailing Address
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Address Line | 6099 NEW TAYLOR RD RIGHT SIDE
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City | ORCHARD PARK
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State | NY
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Zip | 14127
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Country | US
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Telephone | 716-316-4990
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 22894
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 004210-01
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License Number State | NY
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