Provider Demographics
NPI:1023178480
Name:LEVINE, STEPHEN GARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GARY
Last Name:LEVINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 EVERGREEN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029
Mailing Address - Country:US
Mailing Address - Phone:262-367-8298
Mailing Address - Fax:
Practice Address - Street 1:17100 W BLUEMOUND RD
Practice Address - Street 2:SUITE 204
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5950
Practice Address - Country:US
Practice Address - Phone:262-391-5780
Practice Address - Fax:262-754-3712
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1073057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist