MEDICARE: CORISSA CARLSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301017222	MI

General Provider Information

NPI Number	:	1093008880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORISSA CARLSON

Provider Business Mailing Address
First Line	:	42815 GARFIELD RD STE 201
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-1143
Country	:	US
Telephone Number	:	586-333-5328
Fax Number	:

Provider Business Practice Location Address
First Line	:	42815 GARFIELD RD STE 201
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-1143
Country	:	US
Telephone Number	:	586-333-5328
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2011
Last Update Date	:	09/26/2025

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