MEDICARE: BEVILACQUA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1508609868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEVILACQUA LLC

Provider Business Mailing Address
First Line	:	PO BOX 11
Second Line	:
City	:	EL PRADO
State	:	NM
Zip	:	87529-0011
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1518 PASEO DEL PUEBLO NORTE UNIT 11
Second Line	:
City	:	EL PRADO
State	:	NM
Zip	:	87529-8004
Country	:	US
Telephone Number	:	724-244-4815
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LEAH BEVILACQUA
Credential	:
Telephone Number	:	724-244-4815

Provider Enumeration Date	:	06/14/2024
Last Update Date	:	10/23/2024

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Directions to “BEVILACQUA LLC ” Practice Location

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