Provider Demographics
NPI:1265796080
Name:LIVINGSTON, MARK A (LPCIT, SAC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:LPCIT, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7216 S. 37TH PLACE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132
Mailing Address - Country:US
Mailing Address - Phone:414-793-3297
Mailing Address - Fax:
Practice Address - Street 1:2701 S CHASE AVE STE C
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-1482
Practice Address - Country:US
Practice Address - Phone:414-389-6450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16622-130101YA0400X
WI1724-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)