Provider Demographics
NPI:1730312430
Name:LIVINGSTON, KELLY DENISE (MS, PLPE)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DENISE
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:MS, PLPE
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DENISE
Other - Last Name:BELT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 BOB COURTWAY DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-4766
Mailing Address - Country:US
Mailing Address - Phone:501-328-5525
Mailing Address - Fax:501-328-5342
Practice Address - Street 1:1100 BOB COURTWAY DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4766
Practice Address - Country:US
Practice Address - Phone:501-328-5525
Practice Address - Fax:501-328-5342
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR09-45AE-PL103T00000X
AR11-09AE-PL103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103T00000XBehavioral Health & Social Service ProvidersPsychologist