Provider Demographics
NPI:1346334042
Name:LEVINE, JEFFREY MITCHELL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MITCHELL
Last Name:LEVINE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:CT
Mailing Address - Zip Code:06249
Mailing Address - Country:US
Mailing Address - Phone:860-534-1592
Mailing Address - Fax:
Practice Address - Street 1:100 KINGSLEY RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:CT
Practice Address - Zip Code:06249
Practice Address - Country:US
Practice Address - Phone:860-534-1592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001225103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCBHP4848JLMedicaid