Provider Demographics
NPI:1861428328
Name:AXTELL, TIMOTHY TODD (PT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:TODD
Last Name:AXTELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 WILMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-6255
Mailing Address - Country:US
Mailing Address - Phone:989-778-2839
Mailing Address - Fax:989-778-2898
Practice Address - Street 1:3051 KIESEL RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2449
Practice Address - Country:US
Practice Address - Phone:989-778-2839
Practice Address - Fax:989-778-2898
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650B610090OtherBCBS ID#