Provider Demographics
NPI:1184329211
Name:LEVINE, SAMUEL THOMAS
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:THOMAS
Last Name:LEVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:THOMAS
Other - Last Name:LEVINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1700 W OAK AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-3837
Mailing Address - Country:US
Mailing Address - Phone:714-681-6759
Mailing Address - Fax:
Practice Address - Street 1:1700 W OAK AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-3837
Practice Address - Country:US
Practice Address - Phone:714-681-6759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician