Healthcare Provider Details

I. General information

NPI: 1144592072
Provider Name (Legal Business Name): MICHELLE MCCLATCHIE MA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 E WILLOW POINT RD
CORNVILLE AZ
86325-6014
US

IV. Provider business mailing address

PO BOX 1163
CORNVILLE AZ
86325-1163
US

V. Phone/Fax

Practice location:
  • Phone: 928-830-7158
  • Fax:
Mailing address:
  • Phone: 928-830-7158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-13845
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: