Provider Demographics
NPI:1174549075
Name:LEVITT, BRAD W (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:W
Last Name:LEVITT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-2852
Mailing Address - Country:US
Mailing Address - Phone:208-649-7221
Mailing Address - Fax:208-642-2019
Practice Address - Street 1:223 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2852
Practice Address - Country:US
Practice Address - Phone:208-649-7221
Practice Address - Fax:208-642-2019
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202138103T00000X, 103TC0700X
ORT0446106H00000X
IDLMFT3042106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDN6294OtherBC/BS
ID807333100Medicaid
IDN6294OtherBC/BS