Provider Demographics
NPI:1164751657
Name:LEVINE, SUSAN S (LCSW, BCD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:LEVINE
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 COULTER AVE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-2427
Mailing Address - Country:US
Mailing Address - Phone:610-642-9546
Mailing Address - Fax:610-664-1511
Practice Address - Street 1:119 COULTER AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2427
Practice Address - Country:US
Practice Address - Phone:610-642-9546
Practice Address - Fax:610-664-1511
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X
PACW-000407-L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PALE634525Medicare PIN