Provider Demographics
NPI:1679824213
Name:AXELROD, ERICA LYNN
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNN
Last Name:AXELROD
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 1:5 POND DR
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-2207
Mailing Address - Country:US
Mailing Address - Phone:516-935-3828
Mailing Address - Fax:
Practice Address - Street 1:5 POND DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-2207
Practice Address - Country:US
Practice Address - Phone:516-935-3828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-22
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY696020961252Y00000X
NY696021961252Y00000X
NY114093021252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency