Provider Demographics
NPI:1063159556
Name:LEVINE, LAURIE BETH (PHD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:BETH
Last Name:LEVINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 RIDGEWOOD TER
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-2133
Mailing Address - Country:US
Mailing Address - Phone:201-618-6543
Mailing Address - Fax:
Practice Address - Street 1:108 BAKER ST
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-2531
Practice Address - Country:US
Practice Address - Phone:973-761-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37FI00147000106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist