Provider Demographics
NPI:1659736338
Name:LUCK, MICHAEL SHANE (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:LUCK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:SHANE
Other - Middle Name:
Other - Last Name:LUCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:2638 OLD SCHOOL HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-9433
Mailing Address - Country:US
Mailing Address - Phone:480-510-6780
Mailing Address - Fax:
Practice Address - Street 1:61 WEST CENTER
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937
Practice Address - Country:US
Practice Address - Phone:480-510-6780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-22
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-15864101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health