Provider Demographics
NPI:1689936361
Name:LEVINE, NICOLE (MS)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:LEVINE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 CLINTON AVE APT 11F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-1160
Mailing Address - Country:US
Mailing Address - Phone:917-576-7951
Mailing Address - Fax:
Practice Address - Street 1:7000 AUSTIN ST STE 200
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4739
Practice Address - Country:US
Practice Address - Phone:718-762-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174400000XOther Service ProvidersSpecialist