Provider Demographics
NPI:1861736316
Name:AXELROD, SAMANTHA HALLEY (TVI, MSED)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:HALLEY
Last Name:AXELROD
Suffix:
Gender:F
Credentials:TVI, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 VANDERBILT LN
Mailing Address - Street 2:
Mailing Address - City:OLD BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11804-1730
Mailing Address - Country:US
Mailing Address - Phone:516-655-3887
Mailing Address - Fax:
Practice Address - Street 1:10 VANDERBILT LN
Practice Address - Street 2:
Practice Address - City:OLD BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11804-1730
Practice Address - Country:US
Practice Address - Phone:516-655-3887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist