Provider Demographics
NPI:1821552266
Name:LUTTRULL, MICHEAL DEAN (CDP)
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:DEAN
Last Name:LUTTRULL
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 WHEATON WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3440
Mailing Address - Country:US
Mailing Address - Phone:360-373-0155
Mailing Address - Fax:
Practice Address - Street 1:2123 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7531
Practice Address - Country:US
Practice Address - Phone:804-897-7044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60969656101YA0400X
WACO60703545101YA0400X
AZLASAC-7186T101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)