Provider Demographics
NPI:1144927542
Name:LIVINGSTON, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:LIVINGSTON
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 1:330 W 800 S
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:UT
Mailing Address - Zip Code:84647-1929
Mailing Address - Country:US
Mailing Address - Phone:435-262-9901
Mailing Address - Fax:
Practice Address - Street 1:21360 N 1450 E
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-7629
Practice Address - Country:US
Practice Address - Phone:435-262-1217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT175T00000X
UT32253J00000X101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1235458555Medicaid
UT1270465727Medicaid