Healthcare Provider Details

I. General information

NPI: 1760396667
Provider Name (Legal Business Name): LEVI ANDREW WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 PALM BAY RD NE STE 230
PALM BAY FL
32905-3359
US

IV. Provider business mailing address

2475 PALM BAY RD NE STE 230
PALM BAY FL
32905-3359
US

V. Phone/Fax

Practice location:
  • Phone: 321-536-0107
  • Fax:
Mailing address:
  • Phone: 321-536-0107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: