Provider Demographics
NPI:1417092792
Name:LEVINE, GERALD LAWRENCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:LAWRENCE
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 1:7855 BOULEVARD EAST 26H
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047
Mailing Address - Country:US
Mailing Address - Phone:201-854-8161
Mailing Address - Fax:
Practice Address - Street 1:24 FIFTH AVE
Practice Address - Street 2:LOBBY LEVEL SUITE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:212-714-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0052061103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV55441Medicare ID - Type Unspecified