Healthcare Provider Details

I. General information

NPI: 1548779838
Provider Name (Legal Business Name): KRISTEN AXELSEN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VETERAN AVE
LOS ANGELES CA
90024-2704
US

IV. Provider business mailing address

1000 VETERAN AVENUE BOX 957142
LOS ANGELES CA
90095-0001
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-6110
  • Fax:
Mailing address:
  • Phone: 310-825-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: