Provider Demographics
NPI:1285775569
Name:AXTMAN, MYSTAL RAE (MS, LPCC)
Entity type:Individual
Prefix:
First Name:MYSTAL
Middle Name:RAE
Last Name:AXTMAN
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 40TH AVE S STE 115
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4592
Mailing Address - Country:US
Mailing Address - Phone:701-541-1547
Mailing Address - Fax:
Practice Address - Street 1:4675 40TH AVE S STE 115
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4592
Practice Address - Country:US
Practice Address - Phone:701-478-0906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND472-3-1-02-164101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health