Provider Demographics
NPI:1124074729
Name:AXELBERG, LOUISE ANN
Entity type:Individual
Prefix:MRS
First Name:LOUISE
Middle Name:ANN
Last Name:AXELBERG
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:PO BOX 47095
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-7095
Mailing Address - Country:US
Mailing Address - Phone:904-399-0404
Mailing Address - Fax:904-367-0717
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 601
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-399-0404
Practice Address - Fax:904-367-0717
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW43151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ7350Medicare ID - Type UnspecifiedMCARE PROV ID