Provider Demographics
NPI:1891456802
Name:LIVAK, MARK C (LCMHCA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:LIVAK
Suffix:
Gender:M
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 TURF CT
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-6600
Mailing Address - Country:US
Mailing Address - Phone:803-372-8997
Mailing Address - Fax:
Practice Address - Street 1:7751 BALLANTYNE COMMONS PKWY STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2442
Practice Address - Country:US
Practice Address - Phone:704-626-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17157101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health