Provider Demographics
NPI:1073781084
Name:AXMAN, REID (EDS)
Entity Type:Individual
Prefix:MR
First Name:REID
Middle Name:
Last Name:AXMAN
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7040 W ST CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-5048
Mailing Address - Country:US
Mailing Address - Phone:602-605-8151
Mailing Address - Fax:
Practice Address - Street 1:1617 S 67TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-7717
Practice Address - Country:US
Practice Address - Phone:623-707-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3870260103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool