Provider Demographics
NPI:1932613676
Name:MICHAELIS, CAROL LYNN
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:MICHAELIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 COMSTOCK LN
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-8530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1235 MCHENRY AVE STE A&B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5370
Practice Address - Country:US
Practice Address - Phone:209-527-4597
Practice Address - Fax:209-527-4599
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health