Provider Demographics
NPI:1154300234
Name:AXIS-ONE INC
Entity Type:Organization
Organization Name:AXIS-ONE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EMORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGLETARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-475-0402
Mailing Address - Street 1:5149 SOUTH 1500 WEST
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405
Mailing Address - Country:US
Mailing Address - Phone:801-475-0402
Mailing Address - Fax:801-475-7464
Practice Address - Street 1:5149 SOUTH 1500 WEST
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-475-0402
Practice Address - Fax:801-475-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT47306713501101YA0400X
UT3231733501101YM0800X
UT1418053501101YM0800X
101YM0800X
UT50176303501101YM0800X
UT49189582601103T00000X
UT2083338900163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005760001Medicare ID - Type UnspecifiedCHERLY KELSTROM LCSW
000057600Medicare PIN
000077049Medicare ID - Type UnspecifiedJUNE SINGLETARY LCSW