Provider Demographics
NPI:1215695804
Name:AXTELL, DORA L (LMSW)
Entity type:Individual
Prefix:
First Name:DORA
Middle Name:L
Last Name:AXTELL
Suffix:
Gender:F
Credentials:LMSW
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 367
Mailing Address - Street 2:
Mailing Address - City:LAPWAI
Mailing Address - State:ID
Mailing Address - Zip Code:83540-0367
Mailing Address - Country:US
Mailing Address - Phone:208-843-7244
Mailing Address - Fax:208-843-7394
Practice Address - Street 1:111 BEVER GRADE
Practice Address - Street 2:
Practice Address - City:LAPWAI
Practice Address - State:ID
Practice Address - Zip Code:83540
Practice Address - Country:US
Practice Address - Phone:208-843-7244
Practice Address - Fax:208-843-7394
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-41113104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical