Provider Demographics
NPI:1427019462
Name:LEVICK, MITCHELL A (PHD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:A
Last Name:LEVICK
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:PO BOX 20848
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87154-0848
Mailing Address - Country:US
Mailing Address - Phone:505-342-0400
Mailing Address - Fax:
Practice Address - Street 1:9201 MONTGOMERY BLVD NE BLDG 1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2468
Practice Address - Country:US
Practice Address - Phone:505-342-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM638103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP0269Medicaid
NM$$$$$$$$$Medicare PIN