Provider Demographics
NPI:1275871113
Name:MACILVAINE, MICHELLE RUTH (LPC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RUTH
Last Name:MACILVAINE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 S LAVEEN PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-5049
Mailing Address - Country:US
Mailing Address - Phone:602-509-5882
Mailing Address - Fax:
Practice Address - Street 1:4530 E RAY RD STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6095
Practice Address - Country:US
Practice Address - Phone:480-637-5574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-14057101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health