Healthcare Provider Details

I. General information

NPI: 1396227468
Provider Name (Legal Business Name): BENJAMIN P LIVESAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 WISCONSIN AVE STE C
JOPLIN MO
64804-4074
US

IV. Provider business mailing address

101 N MAIN ST PO BOX #101
JOPLIN MO
64802-2201
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-7730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28228
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22305
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number118537
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: