Provider Demographics
NPI:1710123765
Name:LIVINGSTONE, JOHN DALE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DALE
Last Name:LIVINGSTONE
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 1:1355 N UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2721
Mailing Address - Country:US
Mailing Address - Phone:801-221-0223
Mailing Address - Fax:801-221-0291
Practice Address - Street 1:1355 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-221-0223
Practice Address - Fax:801-221-0291
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4923696-2501103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent