Provider Demographics
NPI:1932113024
Name:LEVINE, MICHAEL HARRIS (SCD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:HARRIS
Last Name:LEVINE
Suffix:
Gender:M
Credentials:SCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 W WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-1848
Mailing Address - Country:US
Mailing Address - Phone:623-772-5027
Mailing Address - Fax:
Practice Address - Street 1:235 W WESTERN AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1848
Practice Address - Country:US
Practice Address - Phone:623-772-5027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ567000Medicare UPIN