Healthcare Provider Details

I. General information

NPI: 1710826664
Provider Name (Legal Business Name): AEVUM BH NC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 STATESVILLE BLVD
SALISBURY NC
28144-2201
US

IV. Provider business mailing address

175 ROUTE 70 STE 303
TOMS RIVER NJ
08755-0936
US

V. Phone/Fax

Practice location:
  • Phone: 804-446-1710
  • Fax:
Mailing address:
  • Phone: 804-446-1710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: LEVI LIPOVENKO
Title or Position: CEO
Credential:
Phone: 804-446-1710