Provider Demographics
NPI:1669239687
Name:LEVINE, CLEO
Entity type:Individual
Prefix:
First Name:CLEO
Middle Name:
Last Name:LEVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8903 KEY PENINSULA HWY NW
Mailing Address - Street 2:
Mailing Address - City:LAKEBAY
Mailing Address - State:WA
Mailing Address - Zip Code:98349-9326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8903 KEY PENINSULA HWY NW
Practice Address - Street 2:
Practice Address - City:LAKEBAY
Practice Address - State:WA
Practice Address - Zip Code:98349-9326
Practice Address - Country:US
Practice Address - Phone:601-274-4997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC615722751041C0700X
WACL61526239101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health