Healthcare Provider Details

I. General information

NPI: 1982951190
Provider Name (Legal Business Name): LIVINUS C UBA ICADC, LCDCIII, CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 WINCHESTER AVE
ASHLAND KY
41101-2065
US

IV. Provider business mailing address

3655 WINCHESTER AVE
ASHLAND KY
41101-2065
US

V. Phone/Fax

Practice location:
  • Phone: 606-393-4632
  • Fax: 888-411-4131
Mailing address:
  • Phone: 606-393-4632
  • Fax: 888-411-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number121019
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number710053
License Number StateZZ
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number128644
License Number StateZZ
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number166426
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: