Healthcare Provider Details

I. General information

NPI: 1932613676
Provider Name (Legal Business Name): CAROL LYNN MICHAELIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 04/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 MCHENRY AVE STE A&B
MODESTO CA
95350-5370
US

IV. Provider business mailing address

650 COMSTOCK LN
MANTECA CA
95336-8530
US

V. Phone/Fax

Practice location:
  • Phone: 209-527-4597
  • Fax: 209-527-4599
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: