Provider Demographics
NPI:1508179797
Name:AXELSON, CONNIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:AXELSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 NANTUCKET LN
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-4435
Mailing Address - Country:US
Mailing Address - Phone:516-766-2556
Mailing Address - Fax:
Practice Address - Street 1:15 NANTUCKET LN
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-4435
Practice Address - Country:US
Practice Address - Phone:516-766-2556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008864-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical