Provider Demographics
NPI:1578170734
Name:BEVACQUA, CYNTHIA (LAADC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:BEVACQUA
Suffix:
Gender:F
Credentials:LAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 E. CHAPMAN AVENUE
Mailing Address - Street 2:#48
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4134
Mailing Address - Country:US
Mailing Address - Phone:714-900-7915
Mailing Address - Fax:
Practice Address - Street 1:5215 E CHAPMAN AVE SPC 48
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-4232
Practice Address - Country:US
Practice Address - Phone:714-900-7915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALR03121224101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)