Provider Demographics
NPI:1679068159
Name:LIVINGSTON, DEREK (MS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11075 S STATE ST STE 35
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-5187
Mailing Address - Country:US
Mailing Address - Phone:801-990-4300
Mailing Address - Fax:
Practice Address - Street 1:11075 STATE ST #35
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070
Practice Address - Country:US
Practice Address - Phone:801-990-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10838570-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty