Provider Demographics
NPI:1265490965
Name:LEVINE, SUSAN WOOLLEY (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:WOOLLEY
Last Name:LEVINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:CLARK
Other - Last Name:WOOLLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1738 UNION ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123
Mailing Address - Country:US
Mailing Address - Phone:415-820-3925
Mailing Address - Fax:415-874-9144
Practice Address - Street 1:1738 UNION ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123
Practice Address - Country:US
Practice Address - Phone:415-820-3925
Practice Address - Fax:415-874-9144
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17907103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P55026Medicare UPIN
CA0PL179070Medicare ID - Type Unspecified