Provider Demographics
NPI:1629546189
Name:LIVASY, NICK J (DPT)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:J
Last Name:LIVASY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14515 N OUTER 40 RD STE 110
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5746
Mailing Address - Country:US
Mailing Address - Phone:131-443-4868
Mailing Address - Fax:
Practice Address - Street 1:4020 BUTLER HILL RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1500
Practice Address - Country:US
Practice Address - Phone:314-487-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018039727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist