Healthcare Provider Details

I. General information

NPI: 1225407919
Provider Name (Legal Business Name): IAN G LIVINGSTON APCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 BRENTWOOD DR
GRASS VALLEY CA
95945-5703
US

IV. Provider business mailing address

2165 LARKSPUR LN
REDDING CA
96002-0600
US

V. Phone/Fax

Practice location:
  • Phone: 530-271-1140
  • Fax:
Mailing address:
  • Phone: 530-226-7419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1202170515
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: