Individual
DR. ETHAN R LEVINE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
101 CABARRUS AVE E, CONCORD, NC 28025-3699
(888) 849-7379
(855) 857-7333
Mailing address
101 CABARRUS AVE E, CONCORD, NC 28025-3699
(888) 849-7379
(855) 857-7333
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
—
103TA0700X
Adult Development & Aging Psychologist
Primary
—
—
103TC0700X
Clinical Psychologist
650
NC
103TC2200X
Clinical Child & Adolescent Psychologist
—
—
103TE1100X
Exercise & Sports Psychologist
—
—
103TH0100X
Health Service Psychologist
—
—
103TR0400X
Rehabilitation Psychologist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14040
BCBS
NC
05
—
6001139
—
NC
01
—
P01164443
RR MEDICARE
NC
Enumeration date
03/13/2009
Last updated
04/08/2020
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