Provider Demographics
NPI:1386630382
Name:LIVINGSTON, LEE ASHLEY (PSYD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:ASHLEY
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:PSYD, ABPP
Other - Prefix:DR
Other - First Name:LEE
Other - Middle Name:ASHLEY
Other - Last Name:LIVINGSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD, ABPP
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:915-539-0704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-25
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33756103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010210399Medicaid
VA010210399Medicaid
VA008468M97Medicare ID - Type UnspecifiedC03697