=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144747940
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AXIS MENTAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2017
-----------------------------------------------------
Last Update Date | 10/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1230 W SANTA ANA BLVD
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92703-3835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-501-5979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1230 W SANTA ANA BLVD
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92703-3835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-582-2714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISOR
-----------------------------------------------------
Name | DARRYLE MACKELVEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-948-6086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------