Provider Demographics
NPI:1972080901
Name:BEVACQUA, AMY JOLENE (DPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JOLENE
Last Name:BEVACQUA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13542 W VERNON RD
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-6748
Mailing Address - Country:US
Mailing Address - Phone:814-282-6995
Mailing Address - Fax:
Practice Address - Street 1:11277 VERNON PL
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3717
Practice Address - Country:US
Practice Address - Phone:814-333-5214
Practice Address - Fax:814-333-1482
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT018024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist