=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639526536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AXIOM COUNSELING & THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2016
-----------------------------------------------------
Last Update Date | 05/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7570 W 21ST ST N BUILDING1042 SUITE B
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67205-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-461-8149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11809 W SHERIAC ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67209-4087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-461-8149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | D TODD NICKEL
-----------------------------------------------------
Credential | LCMFT
-----------------------------------------------------
Telephone | 316-461-8149
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 776
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------