Provider Demographics
NPI:1760610653
Name:LEVINE, MARK D (MS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 LAS GALLINAS AVE
Mailing Address - Street 2:SUITE 131
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3618
Mailing Address - Country:US
Mailing Address - Phone:415-297-9190
Mailing Address - Fax:
Practice Address - Street 1:454 LAS GALLINAS AVE
Practice Address - Street 2:SUITE 131
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3618
Practice Address - Country:US
Practice Address - Phone:415-297-9190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI27101YM0800X
NC2935101YP2500X
1-00-0276103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional