Healthcare Provider Details

I. General information

NPI: 1801169602
Provider Name (Legal Business Name): JONATHAN C LIVENGOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E 6TH ST
ERIE PA
16501-1201
US

IV. Provider business mailing address

3 ANN AVE
FALCONER NY
14733-1004
US

V. Phone/Fax

Practice location:
  • Phone: 814-459-2755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: