Provider Demographics
NPI:1215184189
Name:DAHL, MICHAEL (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DAHL
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 E SKYLINE DR APT 507
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-1657
Mailing Address - Country:US
Mailing Address - Phone:253-209-6195
Mailing Address - Fax:
Practice Address - Street 1:1725 E BILBY RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-4430
Practice Address - Country:US
Practice Address - Phone:520-545-5300
Practice Address - Fax:520-545-5316
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3975839103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3975839Medicaid