Healthcare Provider Details

I. General information

NPI: 1366109209
Provider Name (Legal Business Name): MICHELLE FELICIA LIVINGSTON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2021
Last Update Date: 11/28/2021
Certification Date: 11/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 E AZTEC AVE
GALLUP NM
87301-4803
US

IV. Provider business mailing address

4816 MCMAHON BLVD NW APT H59
ALBUQUERQUE NM
87114-5051
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-3120
  • Fax:
Mailing address:
  • Phone: 505-862-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: