Provider Demographics
NPI:1538300025
Name:LEVINE, ETHAN R (PHD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:R
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 1:101 CABARRUS AVE E
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-3699
Mailing Address - Country:US
Mailing Address - Phone:888-849-7379
Mailing Address - Fax:855-857-7333
Practice Address - Street 1:101 CABARRUS AVE E
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3699
Practice Address - Country:US
Practice Address - Phone:888-849-7379
Practice Address - Fax:855-857-7333
Is Sole Proprietor?:No
Enumeration Date:2009-03-13
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TC2200X, 103TE1100X, 103TH0100X, 103TR0400X, 103TA0700X
NC650103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14040OtherBCBS
NC6001139Medicaid
NCP01164443OtherRR MEDICARE
NC6001139Medicaid