Provider Demographics
NPI:1871898809
Name:BEVILACQUA, COLLEEN LYNN (PT)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:LYNN
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2312
Mailing Address - Country:US
Mailing Address - Phone:518-391-3334
Mailing Address - Fax:
Practice Address - Street 1:11 BRUCE ST
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-2312
Practice Address - Country:US
Practice Address - Phone:518-391-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-23
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist