MEDICARE: CARLY BEVACQUA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide		OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	175848	OH

General Provider Information

NPI Number	:	1821603325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY BEVACQUA

Provider Business Mailing Address
First Line	:	6823 FARNSWORTH DR
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44129-4514
Country	:	US
Telephone Number	:	216-644-2344
Fax Number	:

Provider Business Practice Location Address
First Line	:	6823 FARNSWORTH DR
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44129-4514
Country	:	US
Telephone Number	:	216-644-2344
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2020
Last Update Date	:	02/02/2021

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Directions to “ CARLY BEVACQUA ” Practice Location

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