Provider Demographics
NPI:1366984098
Name:WAYAN-LEVINE, MISCHA
Entity type:Individual
Prefix:
First Name:MISCHA
Middle Name:
Last Name:WAYAN-LEVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 S NATURA ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-2172
Mailing Address - Country:US
Mailing Address - Phone:360-820-1015
Mailing Address - Fax:
Practice Address - Street 1:1512 S NATURA ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-2172
Practice Address - Country:US
Practice Address - Phone:360-820-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8603819-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant