Healthcare Provider Details

I. General information

NPI: 1457845182
Provider Name (Legal Business Name): AXIS PSYCHIATRIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2018
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 12TH ST CUT OFF SE STE 140
SALEM OR
97302-1754
US

IV. Provider business mailing address

PO BOX 12926
SALEM OR
97309-0926
US

V. Phone/Fax

Practice location:
  • Phone: 971-304-9306
  • Fax: 503-371-2006
Mailing address:
  • Phone: 615-243-5407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number201701173NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number201701173NP-PP
License Number StateOR

VIII. Authorized Official

Name: TARRA LEANI BAKER
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: MSN, PMHNP, NP
Phone: 615-243-5407