Provider Demographics
NPI:1487213195
Name:AXMAN, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:AXMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-702-4389
Mailing Address - Fax:
Practice Address - Street 1:3650 PACIFIC AVE STE 104B
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-3100
Practice Address - Country:US
Practice Address - Phone:503-395-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACP044998225100000X
225100000X, 390200000X
ORCP044998T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program