Provider Demographics
NPI:1578911822
Name:GHASEMI, AXIE
Entity Type:Individual
Prefix:MS
First Name:AXIE
Middle Name:
Last Name:GHASEMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1209
Mailing Address - Country:US
Mailing Address - Phone:718-375-1200
Mailing Address - Fax:
Practice Address - Street 1:790 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5316
Practice Address - Country:US
Practice Address - Phone:718-388-5175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health