Healthcare Provider Details

I. General information

NPI: 1417879446
Provider Name (Legal Business Name): AXEN BEHAVIORAL HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 HARTFORD TPKE STE G3
VERNON CT
06066-4761
US

IV. Provider business mailing address

281 HARTFORD TPKE STE G3
VERNON CT
06066-4761
US

V. Phone/Fax

Practice location:
  • Phone: 860-341-2837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALI KHAN
Title or Position: MANAGING MEMBER
Credential: PMHNP-BC
Phone: 860-249-3850