Provider Demographics
NPI:1992093249
Name:LEVINE, SUSAN L
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:LEVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 E GILLETTE COURT
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-2492
Mailing Address - Country:US
Mailing Address - Phone:860-651-6156
Mailing Address - Fax:860-217-1550
Practice Address - Street 1:8 E GILLETTE COURT
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-2492
Practice Address - Country:US
Practice Address - Phone:860-651-6156
Practice Address - Fax:860-217-1550
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000580101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor