Healthcare Provider Details

I. General information

NPI: 1629136247
Provider Name (Legal Business Name): MICHAEL MORSE LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S. MAIN
SUPERIOR AZ
85273
US

IV. Provider business mailing address

PO BOX 3160
APACHE JUNCTION AZ
85217-3160
US

V. Phone/Fax

Practice location:
  • Phone: 480-983-0065
  • Fax: 480-288-5339
Mailing address:
  • Phone: 480-983-0065
  • Fax: 480-288-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10836
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: