Basic Information
| Provider Information | |||||||||
| NPI: | 1215081930 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AXELROD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 422 | ||||||||
| Address2: | ACADIA HOSPITAL CORP. | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044020422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079736100 | ||||||||
| FaxNumber: | 2079736109 | ||||||||
| Practice Location | |||||||||
| Address1: | 268 SILLWATER AVENUE | ||||||||
| Address2: | ACADIA HOSPITAL CORP. | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079736100 | ||||||||
| FaxNumber: | 2079736109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 606 | NE | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | PS1237 | ME | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 47037660631 | 05 | NE | MEDICAID |