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General NPI Number Information
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NPI Number | 1972002004
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Entity Type | Organization
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Legal Business Name | ETHAN R. LEVINE, PH.D.
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Dates
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Enumeration Date | 02/05/2018
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Last Update Date | 02/05/2018
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Provider Practice Location Address
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Address Line | 11937 STRAIGHT A WAY LN
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City | RALEIGH
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State | NC
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Zip | 27613-7105
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Country | US
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Telephone | 919-264-3755
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Fax | 919-846-9231
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Provider Business Mailing Address
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Address Line | 11937 STRAIGHT A WAY LN
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City | RALEIGH
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State | NC
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Zip | 27613-7105
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Country | US
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Telephone | 919-264-3755
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Fax | 919-846-9231
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | DR. ETHAN ROY LEVINE
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Credential | PH.D.
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Telephone | 919-264-3755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 650
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License Number State | NC
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