Provider Demographics
NPI:1528532280
Name:LIVELY, CHARLOTTE (LISW-S)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:LIVELY
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 MOUND ST
Mailing Address - Street 2:
Mailing Address - City:THE PLAINS
Mailing Address - State:OH
Mailing Address - Zip Code:45780-1076
Mailing Address - Country:US
Mailing Address - Phone:740-645-8439
Mailing Address - Fax:
Practice Address - Street 1:213 MOUND ST
Practice Address - Street 2:
Practice Address - City:THE PLAINS
Practice Address - State:OH
Practice Address - Zip Code:45780-1076
Practice Address - Country:US
Practice Address - Phone:740-645-8439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WASX61313303104100000X
VA09040146311041C0700X
MD309181041C0700X
OHI.22034811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker