Basic Information
| Provider Information | |||||||||
| NPI: | 1922180736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVIN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | BRONSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEVIN | ||||||||
| OtherFirstName: | BRONSON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1150 S BOBOLINK DR | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530057205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627861139 | ||||||||
| FaxNumber: | 2627851139 | ||||||||
| Practice Location | |||||||||
| Address1: | 16535 W BLUEMOUND RD | ||||||||
| Address2: | # 200 | ||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530055936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625423255 | ||||||||
| FaxNumber: | 2628216180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 2205-057 | WI | X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 2205 | WI | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 1188 | DC | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 0810000987 | VA | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 1695 | MD | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TF0200X | 2205-057 | WI | X | Behavioral Health & Social Service Providers | Psychologist | Forensic | 103TF0200X | 1188 | DC | X | Behavioral Health & Social Service Providers | Psychologist | Forensic |
ID Information
| ID | Type | State | Issuer | Description | 0810000987 | 01 | VA | LICENSE | OTHER | 1695 | 01 | MD | LICENSE | OTHER | 2205-057 | 01 | WI | LICENSE | OTHER | 1188 | 01 | DC | LICENSE | OTHER |