Provider Demographics
NPI:1063381028
Name:LEVY, JUSTIN CHARLES (LICSW)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CHARLES
Last Name:LEVY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 11TH AVE S APT 208
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-5814
Mailing Address - Country:US
Mailing Address - Phone:612-202-9552
Mailing Address - Fax:
Practice Address - Street 1:1612C W LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2549
Practice Address - Country:US
Practice Address - Phone:612-202-9552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-30
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty