Kevin Gordon Carlson, LPCC, LADC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

4790 Issued in MN

Practice address

520 Osborne Rd NE Ste 120
Fridley, MN 55432-2718

Phone

(763) 236-4300

NPI assigned

Jan 15, 2025

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Lyn-Lake Psychotherapy and Wellness LTD.

  • Clinical Psychologist
  • Minneapolis, MN
  • NPI 1609355163
  Medicare reassignment
• Allina Health System

  • Obstetrics & Gynecology Physician
  • Buffalo, MN
  • NPI 1295272342
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1736899200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1738540800000",
    "number": "1205647740",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2925 CHICAGO AVE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554071321",
            "telephone_number": "612-262-9000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "520 OSBORNE RD NE STE 120",
            "city": "FRIDLEY",
            "state": "MN",
            "postal_code": "554322718",
            "telephone_number": "763-236-4300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CARLSON",
        "first_name": "KEVIN",
        "middle_name": "GORDON",
        "credential": "LPCC, LADC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2025-01-15",
        "last_updated": "2025-02-03",
        "certification_date": "2025-02-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "MN",
            "license": "305394",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "MN",
            "license": "4790",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "kcarlson435955@excellian.direct.allina.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CDA/PDF/TXT",
            "address_1": "520 Osborne Rd NE Ste 120",
            "city": "Fridley",
            "state": "MN",
            "country_code": "US",
            "postal_code": "554322718",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Patrick David Carlson, D.P.T
• Carli Carrimon, LADC
• Katelyn Marie Cayton, PT, DPT
• Cedar Healing Service LLC
• Amy Cedar

• Professional Counselor in Fridley, MN
• Providers in Fridley, MN by specialty
• Professional Counselor in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 3, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.