Provider Demographics
NPI:1265130850
Name:FONTANINI-AXELROD, ANGELA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:MARIE
Last Name:FONTANINI-AXELROD
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 1:3391 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-5912
Mailing Address - Country:US
Mailing Address - Phone:207-217-8704
Mailing Address - Fax:
Practice Address - Street 1:1451 BLUESTEM BLVD STE E
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-2619
Practice Address - Country:US
Practice Address - Phone:715-514-0982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI898-58103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool