Provider Demographics
NPI:1699387092
Name:CARLSON, MICAH KEVIN (LCSW)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:KEVIN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 VIA NONA MARIE STE 108
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93923-8637
Mailing Address - Country:US
Mailing Address - Phone:951-743-4283
Mailing Address - Fax:
Practice Address - Street 1:180 WESTGATE DR STE 340
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2490
Practice Address - Country:US
Practice Address - Phone:831-768-6736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1017561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical