Healthcare Provider Details

I. General information

NPI: 1083038301
Provider Name (Legal Business Name): ETHAN LEVIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 GOLF CLUB PKWY
ORLANDO FL
32808-4800
US

IV. Provider business mailing address

1221 W COLONIAL DR STE. 300
ORLANDO FL
32804-7163
US

V. Phone/Fax

Practice location:
  • Phone: 407-852-3300
  • Fax:
Mailing address:
  • Phone: 407-852-3300
  • Fax: 407-852-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ6549
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: