MEDICARE: ROBERT BERNARD LEVINE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY13591	CA

General Provider Information

NPI Number	:	1073724456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT BERNARD LEVINE PHD

Provider Business Mailing Address
First Line	:	PO BOX 1160
Second Line	:
City	:	BROOKINGS
State	:	OR
Zip	:	97415-0030
Country	:	US
Telephone Number	:	707-465-1000
Fax Number	:	707-465-9193

Provider Business Practice Location Address
First Line	:	5905 LAKE EARL DR
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95532-7000
Country	:	US
Telephone Number	:	707-465-1000
Fax Number	:	707-465-9193

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	07/08/2007

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