Provider Demographics
NPI:1407221633
Name:LIVELY, KATHLEEN DIANNE (LMSW-AP, LCPPA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DIANNE
Last Name:LIVELY
Suffix:
Gender:F
Credentials:LMSW-AP, LCPPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 E COPELAND RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-4910
Mailing Address - Country:US
Mailing Address - Phone:817-522-5052
Mailing Address - Fax:817-277-5610
Practice Address - Street 1:1112 E COPELAND RD
Practice Address - Street 2:SUITE 310
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-4910
Practice Address - Country:US
Practice Address - Phone:817-522-5052
Practice Address - Fax:817-277-5610
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34234104100000X
TXD03635A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker