Provider Demographics
NPI:1063485399
Name:GORDON-LEVINE, MIMI (LCSW)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:GORDON-LEVINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 E 3900 S
Mailing Address - Street 2:STE A160
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1215
Mailing Address - Country:US
Mailing Address - Phone:801-264-2325
Mailing Address - Fax:
Practice Address - Street 1:1141 E 3900 S
Practice Address - Street 2:STE A160
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1215
Practice Address - Country:US
Practice Address - Phone:801-264-2325
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9414096335011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS76351Medicare UPIN