Provider Demographics
NPI:1073634259
Name:LEVENSON, RISA LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RISA
Middle Name:LYNN
Last Name:LEVENSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 PARK AVE
Mailing Address - Street 2:SUITE 356
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3976
Mailing Address - Country:US
Mailing Address - Phone:631-784-7761
Mailing Address - Fax:631-784-7831
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:SUITE 356
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3976
Practice Address - Country:US
Practice Address - Phone:631-784-7761
Practice Address - Fax:631-784-7831
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013873-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01949802Medicaid
NYVM0101Medicare ID - Type UnspecifiedPSYCHOLOGIST