Provider Demographics
NPI:1861581803
Name:COOTER, MICHAEL HAROLD (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HAROLD
Last Name:COOTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7219 N LITCHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LUKE AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85309-1529
Mailing Address - Country:US
Mailing Address - Phone:623-856-7579
Mailing Address - Fax:623-856-4433
Practice Address - Street 1:7219 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:LUKE AFB
Practice Address - State:AZ
Practice Address - Zip Code:85309-1529
Practice Address - Country:US
Practice Address - Phone:623-856-7579
Practice Address - Fax:623-856-4433
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW 119661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLCSW11966OtherLCSW