Provider Demographics
NPI:1457845182
Name:AXIS PSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:AXIS PSYCHIATRIC SERVICES, LLC
Other - Org Name:AXIS PSYCHIATRIC SERVICES LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TARRA
Authorized Official - Middle Name:LEANI
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, PMHNP, NP
Authorized Official - Phone:615-243-5407
Mailing Address - Street 1:PO BOX 12926
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-0926
Mailing Address - Country:US
Mailing Address - Phone:615-243-5407
Mailing Address - Fax:
Practice Address - Street 1:4035 12TH ST CUT OFF SE STE 140
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1754
Practice Address - Country:US
Practice Address - Phone:971-304-9306
Practice Address - Fax:503-371-2006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-16
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201701173NP-PP2084P0800X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1740736156OtherNPI