Basic Information
| Provider Information | |||||||||
| NPI: | 1962473298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVIN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 TAUGHANNOCK BLVD | ||||||||
| Address2: | PO BOX 366 | ||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072774035 | ||||||||
| FaxNumber: | 6072773888 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 EVERGREEN STREET | ||||||||
| Address2: | |||||||||
| City: | DRYDEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072731300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 014709 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 02145224 | 05 | NY | MEDICAID |