Provider Demographics
NPI:1821552266
Name:LUTTRULL, MICHEAL DEAN (LAAC)
Entity type:Individual
Prefix:
First Name:MICHEAL
Middle Name:DEAN
Last Name:LUTTRULL
Suffix:
Gender:
Credentials:LAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31636 N CACTUS DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-7242
Mailing Address - Country:US
Mailing Address - Phone:480-522-0566
Mailing Address - Fax:
Practice Address - Street 1:31636 N CACTUS DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-7242
Practice Address - Country:US
Practice Address - Phone:480-522-0566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60703545101YA0400X
AZLAAC-15461101YA0400X
WACP60969656101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)