Provider Demographics
NPI:1699835546
Name:LEVAN, COLLISE BELANSKY (MSW)
Entity Type:Individual
Prefix:MS
First Name:COLLISE
Middle Name:BELANSKY
Last Name:LEVAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:COLLISE
Other - Middle Name:ELIZABETH
Other - Last Name:BELANSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9201 WALLACE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6451
Mailing Address - Country:US
Mailing Address - Phone:505-823-9310
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:BOX 200
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2745
Practice Address - Country:US
Practice Address - Phone:505-272-4763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-25331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM890285OtherPROVIDER BILLING NUMBER