Healthcare Provider Details

I. General information

NPI: 1386879674
Provider Name (Legal Business Name): HEATHER AXMAN L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 11/17/2024
Certification Date: 11/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MOUNTAIN PARK PLAZA
WEST DOVER VT
05356-9999
US

IV. Provider business mailing address

PO BOX 51
WILMINGTON VT
05363-0051
US

V. Phone/Fax

Practice location:
  • Phone: 802-464-8105
  • Fax: 802-923-3912
Mailing address:
  • Phone: 954-554-2368
  • Fax: 802-923-3912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151.0125990
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMCAP.0100249
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW9437
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number079468
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0082832
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: