Basic Information
| Provider Information | |||||||||
| NPI: | 1528582418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIVINGSTON | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | DWAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3108 COUNTRY DANCER AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109049711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 731 MALL RING CIR STE 215 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890146691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025476971 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2017 | ||||||||
| LastUpdateDate: | 08/01/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT | NV | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT | 01 | NV | REGISTERED BEHAVIOR TECHNICIAN | OTHER |