Basic Information
| Provider Information | |||||||||
| NPI: | 1679971782 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIVANOS | ||||||||
| FirstName: | ELISA | ||||||||
| MiddleName: | ANTOINETTE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 BROADWAY | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100189226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128408410 | ||||||||
| FaxNumber: | 2128408415 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 BROADWAY | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100189226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128408410 | ||||||||
| FaxNumber: | 2128408415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2014 | ||||||||
| LastUpdateDate: | 01/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 020922 | NY | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.