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General NPI Number Information
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NPI Number | 1821552266
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Entity Type | Individual
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Provider Name | MICHEAL DEAN LUTTRULL LAAC
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Gender | Male
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Dates
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Enumeration Date | 01/30/2019
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Last Update Date | 03/18/2025
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Provider Practice Location Address
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Address Line | 31636 N CACTUS DR
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City | SAN TAN VALLEY
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State | AZ
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Zip | 85143-7242
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Country | US
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Telephone | 480-522-0566
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Fax |
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Provider Business Mailing Address
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Address Line | 31636 N CACTUS DR
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City | SAN TAN VALLEY
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State | AZ
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Zip | 85143-7242
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Country | US
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Telephone | 480-522-0566
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CO60703545
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LAAC-15461
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CP60969656
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License Number State | WA
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