MEDICARE: MICHELLE RUTH MACILVAINE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC-14057	AZ
2	101YP2500X	Professional Counselor	LPC-14057	AZ

General Provider Information

NPI Number	:	1275871113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE RUTH MACILVAINE LPC

Provider Business Mailing Address
First Line	:	64 S LAVEEN PL
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85226-5049
Country	:	US
Telephone Number	:	602-509-5882
Fax Number	:

Provider Business Practice Location Address
First Line	:	4530 E RAY RD STE 120
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-6095
Country	:	US
Telephone Number	:	480-637-5574
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2013
Last Update Date	:	03/14/2024

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