Healthcare Provider Details

I. General information

NPI: 1124965504
Provider Name (Legal Business Name): ADAM CARLSON
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: WILLOW CARLSON

II. Dates (important events)

Enumeration Date: 05/02/2026
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1752 CAPITAL ST
ELGIN IL
60124-7896
US

IV. Provider business mailing address

605 GARDEN RD
DEKALB IL
60115-2303
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-3680
  • Fax: 847-695-3680
Mailing address:
  • Phone: 503-726-9362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: