Provider Demographics
NPI:1114498268
Name:AXELROD, ALYSSA JEANNETTE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:JEANNETTE
Last Name:AXELROD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BLAKESLEE RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-5212
Mailing Address - Country:US
Mailing Address - Phone:203-868-1853
Mailing Address - Fax:
Practice Address - Street 1:17 BLAKESLEE RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-5212
Practice Address - Country:US
Practice Address - Phone:203-868-1853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11167101YM0800X, 1041C0700X
101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health