Provider Demographics
NPI:1285743070
Name:LIVINGSTON, CHARLES CLAY (MA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:CLAY
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 KENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-3035
Mailing Address - Country:US
Mailing Address - Phone:269-344-0331
Mailing Address - Fax:
Practice Address - Street 1:471 W SOUTH ST
Practice Address - Street 2:41-C
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007
Practice Address - Country:US
Practice Address - Phone:269-226-2623
Practice Address - Fax:269-226-2622
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005851103TC0700X
MI68010650881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical