Provider Demographics
NPI:1093548802
Name:AXELROD, AMANDA DAWN (MS, LLMFT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:AXELROD
Suffix:
Gender:F
Credentials:MS, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27112 GATEWAY DR S APT 106
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4954
Mailing Address - Country:US
Mailing Address - Phone:936-446-9476
Mailing Address - Fax:
Practice Address - Street 1:711 E GRAND RIVER AVE STE A
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2474
Practice Address - Country:US
Practice Address - Phone:936-446-9476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4151001155106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist