Provider Demographics
NPI:1407946684
Name:LEVINE, JODY BRAND (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:BRAND
Last Name:LEVINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 TOWN CENTER DRIVE #411
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20910
Mailing Address - Country:US
Mailing Address - Phone:703-437-3236
Mailing Address - Fax:703-435-7422
Practice Address - Street 1:1800 TOWN CENTER DRIVE #411
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20910
Practice Address - Country:US
Practice Address - Phone:703-437-3236
Practice Address - Fax:703-435-7422
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03646104100000X
VA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
011032OtherVALUE OPTIONS
VA211372OtherANTHEM BCBS
010569R74Medicare ID - Type Unspecified