Provider Demographics
NPI:1962093625
Name:LIVENGOOD, GEORGE (MFT 52124)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:LIVENGOOD
Suffix:
Gender:M
Credentials:MFT 52124
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6714 BALBOA BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5570
Mailing Address - Country:US
Mailing Address - Phone:917-674-3459
Mailing Address - Fax:
Practice Address - Street 1:6714 BALBOA BLVD APT 2
Practice Address - Street 2:
Practice Address - City:LAKE BALBOA
Practice Address - State:CA
Practice Address - Zip Code:91406-5570
Practice Address - Country:US
Practice Address - Phone:917-674-3459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist