Healthcare Provider Details

I. General information

NPI: 1184553877
Provider Name (Legal Business Name): MICHAEL ROBERT CARLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5748 LAGUNA PARK DR
ELK GROVE CA
95758-4754
US

IV. Provider business mailing address

5748 LAGUNA PARK DR
ELK GROVE CA
95758-4754
US

V. Phone/Fax

Practice location:
  • Phone: 916-519-9424
  • Fax:
Mailing address:
  • Phone: 916-519-9424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: