Provider Demographics
NPI:1952472300
Name:AXELRAD, KEVIN JAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAY
Last Name:AXELRAD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4188 SANDY HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-3328
Mailing Address - Country:US
Mailing Address - Phone:805-529-3506
Mailing Address - Fax:805-523-7426
Practice Address - Street 1:1137 2ND ST
Practice Address - Street 2:SUITE 207
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5011
Practice Address - Country:US
Practice Address - Phone:310-393-2186
Practice Address - Fax:805-523-7426
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 7943103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist