Provider Demographics
NPI:1194870246
Name:AXELROD, LESLIE SANDERS
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:SANDERS
Last Name:AXELROD
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:SANDERS
Other - Last Name:AXELROD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:10 VANDERBILT LN
Mailing Address - Street 2:
Mailing Address - City:OLD BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11804-1730
Mailing Address - Country:US
Mailing Address - Phone:516-752-1926
Mailing Address - Fax:561-752-1926
Practice Address - Street 1:10 VANDERBILT LN
Practice Address - Street 2:
Practice Address - City:OLD BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11804-1730
Practice Address - Country:US
Practice Address - Phone:516-752-1926
Practice Address - Fax:561-752-1926
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001622-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered