Provider Demographics
NPI:1316374754
Name:LIVINGSTON, ROBERTA DARLENE (LMP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:DARLENE
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 W CLEARWATER AVE STE 14
Mailing Address - Street 2:MARINELAND EAST
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1980
Mailing Address - Country:US
Mailing Address - Phone:509-572-2900
Mailing Address - Fax:
Practice Address - Street 1:5219 W CLEARWATER AVE STE 14
Practice Address - Street 2:MARINELAND EAST
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1980
Practice Address - Country:US
Practice Address - Phone:509-572-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60401637225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist