Provider Demographics
NPI:1477627412
Name:LIVINGSTON, LARRY (PHD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-4665
Mailing Address - Country:US
Mailing Address - Phone:217-877-9117
Mailing Address - Fax:
Practice Address - Street 1:320 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-4665
Practice Address - Country:US
Practice Address - Phone:217-877-9117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490036701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL937280Medicare ID - Type Unspecified
L034597937280Medicare UPIN