Provider Demographics
NPI:1083030324
Name:LEVINE, DELISA LEE
Entity Type:Individual
Prefix:MRS
First Name:DELISA
Middle Name:LEE
Last Name:LEVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DELISA
Other - Middle Name:LEE
Other - Last Name:EBERWEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11363 DULCET AVE
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-2156
Mailing Address - Country:US
Mailing Address - Phone:818-428-5718
Mailing Address - Fax:
Practice Address - Street 1:3655 ALAMO ST STE 300
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2187
Practice Address - Country:US
Practice Address - Phone:818-428-5718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA116175106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL