Provider Demographics
NPI:1235958836
Name:LIVAN, SHENTELLE MARIE (LPA)
Entity type:Individual
Prefix:
First Name:SHENTELLE
Middle Name:MARIE
Last Name:LIVAN
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 GREEN RD STE 103
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2848
Mailing Address - Country:US
Mailing Address - Phone:919-872-6220
Mailing Address - Fax:919-872-6223
Practice Address - Street 1:4805 GREEN RD STE 103
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-2848
Practice Address - Country:US
Practice Address - Phone:198-726-2209
Practice Address - Fax:919-872-6223
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6658103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist