Basic Information
| Provider Information | |||||||||
| NPI: | 1679068159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIVINGSTON | ||||||||
| FirstName: | DEREK | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11075 S STATE ST STE 35 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840705187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019904300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11075 STATE ST #35 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019904300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2018 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 10838570-6009 | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.