Basic Information
Provider Information | |||||||||
NPI: | 1730312430 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIVINGSTON | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | DENISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, PLPE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BELT | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | DENISE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1100 BOB COURTWAY DR | ||||||||
Address2: |   | ||||||||
City: | CONWAY | ||||||||
State: | AR | ||||||||
PostalCode: | 720324766 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013285525 | ||||||||
FaxNumber: | 5013285342 | ||||||||
Practice Location | |||||||||
Address1: | 1100 BOB COURTWAY DR | ||||||||
Address2: |   | ||||||||
City: | CONWAY | ||||||||
State: | AR | ||||||||
PostalCode: | 720324766 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013285525 | ||||||||
FaxNumber: | 5013285342 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2009 | ||||||||
LastUpdateDate: | 05/01/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 103T00000X | 09-45AE-PL | AR | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TC1900X | 11-09AE-PL | AR | Y |   | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.