Provider Demographics
NPI:1497798631
Name:LEVINE, LAURENCE S (PSYD, ABPP-CN)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:S
Last Name:LEVINE
Suffix:
Gender:M
Credentials:PSYD, ABPP-CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 SW BROMELIA TER
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7145
Mailing Address - Country:US
Mailing Address - Phone:561-743-0147
Mailing Address - Fax:772-463-0246
Practice Address - Street 1:3801 PGA BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-2758
Practice Address - Country:US
Practice Address - Phone:561-743-0147
Practice Address - Fax:772-463-0246
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4160103G00000X, 103G00000X
MA3445103G00000X
PAPS005154L103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73432Medicare ID - Type Unspecified
FLRO3902Medicare UPIN