Provider Demographics
NPI:1093800799
Name:MICHELSON, CAROL (MFT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:MICHELSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 CYPRESS ST STE B
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5458
Mailing Address - Country:US
Mailing Address - Phone:707-962-4696
Mailing Address - Fax:
Practice Address - Street 1:347 CYPRESS ST STE B
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-962-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49430106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist