Provider Demographics
NPI:1386072908
Name:AXELROD, RANDI
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:
Last Name:AXELROD
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 1:317 W 21ST ST
Mailing Address - Street 2:3A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-3010
Mailing Address - Country:US
Mailing Address - Phone:808-783-8117
Mailing Address - Fax:
Practice Address - Street 1:317 W 21ST ST
Practice Address - Street 2:3A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-3010
Practice Address - Country:US
Practice Address - Phone:808-783-8117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY673773359174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist