Basic Information
Provider Information | |||||||||
NPI: | 1073979936 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AXELROD | ||||||||
FirstName: | MALLORY | ||||||||
MiddleName: | RUTH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GAMER | ||||||||
OtherFirstName: | MALLORY | ||||||||
OtherMiddleName: | RUTH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5994 MYRTLE AVE | ||||||||
Address2: |   | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908053515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2246192640 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10929 SOUTH ST STE 214B | ||||||||
Address2: |   | ||||||||
City: | CERRITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 907035374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629245526 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/07/2016 | ||||||||
LastUpdateDate: | 11/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149.017634 | IL | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | ASW69967 | CA | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCSW72307 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 1922136076 | 05 | CA |   | MEDICAID |