Healthcare Provider Details

I. General information

NPI: 1770837064
Provider Name (Legal Business Name): WILLIAM EDWARD LIVINGSTON MA LLP CAADC SAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26184 OUTER DR
LINCOLN PARK MI
48146-2084
US

IV. Provider business mailing address

440 RIVIERA DR
SAINT CLAIR SHORES MI
48080-3015
US

V. Phone/Fax

Practice location:
  • Phone: 313-389-7275
  • Fax:
Mailing address:
  • Phone: 248-345-3977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number6361006346
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361006346
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: