Provider Demographics
NPI:1629147855
Name:LEVINE, SANDRA MARKLEY (MA, L,LP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:MARKLEY
Last Name:LEVINE
Suffix:
Gender:F
Credentials:MA, L,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 BLUE SMOKE TRL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-6704
Mailing Address - Country:US
Mailing Address - Phone:574-255-5995
Mailing Address - Fax:
Practice Address - Street 1:960 E STATE ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-9339
Practice Address - Country:US
Practice Address - Phone:269-445-2451
Practice Address - Fax:269-445-3836
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008263103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A46077Medicare ID - Type Unspecified