1780993626 NPI number — MRS. COURTNEY JOANNE AXON MSW, LICSW

Table of content: MRS. COURTNEY JOANNE AXON MSW, LICSW (NPI 1780993626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780993626 NPI number — MRS. COURTNEY JOANNE AXON MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AXON
Provider First Name:
COURTNEY
Provider Middle Name:
JOANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
IVANOFF
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
JOANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780993626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36 CORDAGE PARK CIR STE 326
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02360-7320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-746-0215
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36 CORDAGE PARK CIR STE 326
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02360-7320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-746-0215
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  122494 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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