Basic Information
Provider Information
NPI: 1003003849
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEVIN
FirstName: ELENA
MiddleName: SHARON
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 150 W 20TH AVE
Address2:  
City: SAN MATEO
State: CA
PostalCode: 944031341
CountryCode: US
TelephoneNumber: 6503728569
FaxNumber: 6503417389
Practice Location
Address1: 150 W 20TH AVE
Address2:  
City: SAN MATEO
State: CA
PostalCode: 944031341
CountryCode: US
TelephoneNumber: 6503728569
FaxNumber: 6503417389
Other Information
ProviderEnumerationDate: 09/25/2007
LastUpdateDate: 09/25/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106H00000X  Y Behavioral Health & Social Service ProvidersMarriage & Family Therapist 

No ID Information.


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