Provider Demographics
NPI:1417593161
Name:TOOTHAKER, MICHAEL JAY (CACIII)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAY
Last Name:TOOTHAKER
Suffix:
Gender:M
Credentials:CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 773705
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80477-3705
Mailing Address - Country:US
Mailing Address - Phone:970-761-2207
Mailing Address - Fax:
Practice Address - Street 1:320 OAK ST.
Practice Address - Street 2:
Practice Address - City:STEAMBOAT
Practice Address - State:CO
Practice Address - Zip Code:80477
Practice Address - Country:US
Practice Address - Phone:970-761-2207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2662101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)