Healthcare Provider Details

I. General information

NPI: 1164588489
Provider Name (Legal Business Name): MICHAEL DAVID LUSTER L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15650 N BLACK CANYON HWY B 130
PHOENIX AZ
85053-4064
US

IV. Provider business mailing address

6708 W UTOPIA RD
GLENDALE AZ
85308-5507
US

V. Phone/Fax

Practice location:
  • Phone: 602-548-8733
  • Fax: 602-548-3112
Mailing address:
  • Phone: 623-566-0398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberL.P.C 2479
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: