Provider Demographics
NPI:1629141163
Name:LIVE OAK, INC.
Entity Type:Organization
Organization Name:LIVE OAK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:CORINA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:TEOFILO MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-805-0395
Mailing Address - Street 1:1300 W BELMONT AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3200
Mailing Address - Country:US
Mailing Address - Phone:773-880-1310
Mailing Address - Fax:773-880-1321
Practice Address - Street 1:1300 W BELMONT AVE
Practice Address - Street 2:SUITE #400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3200
Practice Address - Country:US
Practice Address - Phone:773-880-1310
Practice Address - Fax:773-880-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490034311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty