Provider Demographics
NPI:1508559261
Name:LEVINE, DAVID JACOB
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JACOB
Last Name:LEVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ASHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-3239
Mailing Address - Country:US
Mailing Address - Phone:203-501-9131
Mailing Address - Fax:
Practice Address - Street 1:3 ASHWOOD LN
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-3239
Practice Address - Country:US
Practice Address - Phone:203-501-9131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTRBT023-253870106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician