Provider Demographics
NPI:1124681986
Name:LIVESAY, GRAHAM
Entity type:Individual
Prefix:
First Name:GRAHAM
Middle Name:
Last Name:LIVESAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 PIONEER CT STE B
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2015 PIONEER CT STE B
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1736
Practice Address - Country:US
Practice Address - Phone:650-348-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC13305101YP2500X
CAAPCC6195101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional