Provider Demographics
NPI:1306322011
Name:LEVINE, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LEVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3326 GLENHURST PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-2313
Mailing Address - Country:US
Mailing Address - Phone:513-307-7682
Mailing Address - Fax:
Practice Address - Street 1:11438 LEBANON RD UNIT H
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-6201
Practice Address - Country:US
Practice Address - Phone:513-666-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH071054101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)