Provider Demographics
NPI:1205404795
Name:AXEL, ANDREW (PSS, CADC-R)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:AXEL
Suffix:
Gender:M
Credentials:PSS, CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1257
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:OR
Mailing Address - Zip Code:97535-1257
Mailing Address - Country:US
Mailing Address - Phone:541-535-4133
Mailing Address - Fax:
Practice Address - Street 1:149 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:OR
Practice Address - Zip Code:97535-6631
Practice Address - Country:US
Practice Address - Phone:541-535-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-18-552101YA0400X
OR12-CRM-19175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist