Healthcare Provider Details

I. General information

NPI: 1679401152
Provider Name (Legal Business Name): BRANDON ELIJAH LEVINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 IRVINGTON AVE
SOUTH ORANGE NJ
07079-1904
US

IV. Provider business mailing address

158 SUMMIT AVE
BLOOMFIELD NJ
07003-3888
US

V. Phone/Fax

Practice location:
  • Phone: 862-451-3208
  • Fax:
Mailing address:
  • Phone: 862-451-3208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: