Provider Demographics
NPI:1851426159
Name:LEVINE, ELAINE S (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:S
Last Name:LEVINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5327
Mailing Address - Country:US
Mailing Address - Phone:575-522-5466
Mailing Address - Fax:
Practice Address - Street 1:1395 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5327
Practice Address - Country:US
Practice Address - Phone:505-522-5466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM189103TC2200X
NM0001103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMVNM0191Medicaid
NM0000N5897Medicaid