Provider Demographics
NPI:1124146105
Name:LEVINE, BRUCE L (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:L
Last Name:LEVINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 S MAIN ST
Mailing Address - Street 2:PO BOX 957
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-2022
Mailing Address - Country:US
Mailing Address - Phone:603-676-7711
Mailing Address - Fax:603-676-7711
Practice Address - Street 1:53 S MAIN ST
Practice Address - Street 2:SUITE 302
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-2022
Practice Address - Country:US
Practice Address - Phone:603-676-7711
Practice Address - Fax:603-676-7711
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT48-618103TC0700X
NH421103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0954Medicaid
NH30420051Medicaid
NH30420051Medicaid
NHRE0498Medicare ID - Type UnspecifiedMEDICARE