Provider Demographics
NPI:1336292739
Name:LIVINGSTON, SHANNON HEIDE (LSCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:HEIDE
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 OKLAHOMA ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66046-4830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2537 EISENHOWER RD
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-9482
Practice Address - Country:US
Practice Address - Phone:785-242-2183
Practice Address - Fax:785-242-1859
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 25051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSS11253Medicare UPIN
KS070652Medicare ID - Type UnspecifiedMEDICARE