Provider Demographics
NPI:1447255237
Name:KLUK, MICHAEL (MBA,MA, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:KLUK
Suffix:
Gender:M
Credentials:MBA,MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4877 N TERRITORY AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-5960
Mailing Address - Country:US
Mailing Address - Phone:520-529-0285
Mailing Address - Fax:
Practice Address - Street 1:4877 N TERRITORY AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-5960
Practice Address - Country:US
Practice Address - Phone:520-529-0285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1779235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ957269OtherAHCCCS