Provider Demographics
NPI:1558722413
Name:LIVINGSTON, CHERILYN
Entity Type:Individual
Prefix:
First Name:CHERILYN
Middle Name:
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 TIMBERIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710
Mailing Address - Country:US
Mailing Address - Phone:586-489-8918
Mailing Address - Fax:
Practice Address - Street 1:111 WELLMORE DRIVE
Practice Address - Street 2:
Practice Address - City:TEGA CAY
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:586-489-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3365224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant