Provider Demographics
NPI:1013784552
Name:LIVENGOOD, JOHN MATTHEW
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MATTHEW
Last Name:LIVENGOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:LIVENGOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1167 NE 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4973
Mailing Address - Country:US
Mailing Address - Phone:503-360-8887
Mailing Address - Fax:
Practice Address - Street 1:11 NE MLK BLVD STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3579
Practice Address - Country:US
Practice Address - Phone:971-350-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health