Provider Demographics
NPI:1902583784
Name:AXELROD, CASSIDY
Entity type:Individual
Prefix:
First Name:CASSIDY
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 1:15322 SE ARISTA DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97267-2655
Mailing Address - Country:US
Mailing Address - Phone:760-518-3326
Mailing Address - Fax:
Practice Address - Street 1:15322 SE ARISTA DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97267-2655
Practice Address - Country:US
Practice Address - Phone:760-518-3326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist