Provider Demographics
NPI:1073724456
Name:LEVINE, ROBERT BERNARD (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BERNARD
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:PO BOX 1160
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0030
Mailing Address - Country:US
Mailing Address - Phone:707-465-1000
Mailing Address - Fax:707-465-9193
Practice Address - Street 1:5905 LAKE EARL DR
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95532-7000
Practice Address - Country:US
Practice Address - Phone:707-465-1000
Practice Address - Fax:707-465-9193
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13591103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical