Provider Demographics
NPI:1164640132
Name:LEVIN, JEROME DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:DAVID
Last Name:LEVIN
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 309
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-0309
Mailing Address - Country:US
Mailing Address - Phone:631-369-0922
Mailing Address - Fax:631-369-9382
Practice Address - Street 1:131 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2801
Practice Address - Country:US
Practice Address - Phone:631-727-8150
Practice Address - Fax:631-369-9382
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0005941101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health