Provider Demographics
NPI: | 1619553963 |
---|---|
Name: | AXIS FOR AUTISM LLC |
Entity Type: | Organization |
Organization Name: | AXIS FOR AUTISM LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | COO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ANDREA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | STEVENS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 602-413-5397 |
Mailing Address - Street 1: | 5844 E LAFAYETTE BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | PHOENIX |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85018-4659 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1645 E MISSOURI AVE STE 320 |
Practice Address - Street 2: | |
Practice Address - City: | PHOENIX |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85016-3035 |
Practice Address - Country: | US |
Practice Address - Phone: | 602-888-8882 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-03-18 |
Last Update Date: | 2023-06-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Single Specialty | |
No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | Group - Single Specialty |