Provider Demographics
NPI:1306862297
Name:LEVINE, RANDY (PHD)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
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 1:7360 NW 17TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-1000
Mailing Address - Country:US
Mailing Address - Phone:954-965-9228
Mailing Address - Fax:954-966-2208
Practice Address - Street 1:2450 HOLLYWOOD BLVD STE 303A
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6624
Practice Address - Country:US
Practice Address - Phone:954-965-9228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY003923103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73188Medicare ID - Type UnspecifiedPSYCHOLOGIST