Provider Demographics
NPI:1619910189
Name:MCCLUSKEY, MICHAEL E (LPC, LISAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:MCCLUSKEY
Suffix:
Gender:M
Credentials:LPC, LISAC
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 1309
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-1309
Mailing Address - Country:US
Mailing Address - Phone:928-855-7493
Mailing Address - Fax:
Practice Address - Street 1:2187 SWANSON AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6838
Practice Address - Country:US
Practice Address - Phone:928-855-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-1414101YA0400X
AZLPC-2374101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ615049OtherAHCCCS #