Provider Demographics
NPI:1043300098
Name:LIVINGSTON, MARY H (MED, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:MED, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 BETHUNE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-4704
Mailing Address - Country:US
Mailing Address - Phone:910-484-6383
Mailing Address - Fax:
Practice Address - Street 1:109 BRADFORD AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5401
Practice Address - Country:US
Practice Address - Phone:910-323-0601
Practice Address - Fax:910-222-6547
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPC 2815101YM0800X
NCNCC 38985101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102791Medicaid