Provider Demographics
NPI:1164588489
Name:LUSTER, MICHAEL DAVID (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:LUSTER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6708 W UTOPIA RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5507
Mailing Address - Country:US
Mailing Address - Phone:623-566-0398
Mailing Address - Fax:
Practice Address - Street 1:15650 N BLACK CANYON HWY
Practice Address - Street 2:B 130
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4064
Practice Address - Country:US
Practice Address - Phone:602-548-8733
Practice Address - Fax:602-548-3112
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL.P.C 2479101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional