MEDICARE: MS. ELISE LEONA LIVESEY MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT006923	GA

General Provider Information

NPI Number	:	1306344452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELISE LEONA LIVESEY MS

Provider Business Mailing Address
First Line	:	695 OXFORD HALL DR
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-6004
Country	:	US
Telephone Number	:	678-983-9159
Fax Number	:

Provider Business Practice Location Address
First Line	:	5408 PARK CIR
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-2260
Country	:	US
Telephone Number	:	147-023-4755
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2018
Last Update Date	:	01/23/2018

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