Provider Demographics
NPI:1336618586
Name:AXELROD, ELAINE R (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:R
Last Name: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 1:123 S BROAD ST STE 2048
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19109-1051
Mailing Address - Country:US
Mailing Address - Phone:215-732-5187
Mailing Address - Fax:
Practice Address - Street 1:123 S BROAD ST STE 2048
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19109-1051
Practice Address - Country:US
Practice Address - Phone:215-732-5187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004751L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0Other0