Healthcare Provider Details

I. General information

NPI: 1841750064
Provider Name (Legal Business Name): JEREMY IAN LEVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W NORTHERN AVE
PUEBLO CO
81004-3111
US

IV. Provider business mailing address

1820 EL DORADO AVE
LA HABRA CA
90631-4408
US

V. Phone/Fax

Practice location:
  • Phone: 562-536-1692
  • Fax:
Mailing address:
  • Phone: 562-697-0224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP.0005212
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: