Provider Demographics
NPI:1922208396
Name:LEVY, BRUCE G
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:G
Last Name:LEVY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3860
Mailing Address - Country:US
Mailing Address - Phone:415-608-4888
Mailing Address - Fax:
Practice Address - Street 1:205 CAMINO ALTO CT
Practice Address - Street 2:SUITE 160
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-4312
Practice Address - Country:US
Practice Address - Phone:415-608-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 11826106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist