Provider Demographics
NPI:1366204000
Name:AXON BODYWORK THERAPIES LLC
Entity type:Organization
Organization Name:AXON BODYWORK THERAPIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDIDA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:COSENTINO
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, CMA
Authorized Official - Phone:331-806-6094
Mailing Address - Street 1:2575 SURREY CT
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4447
Mailing Address - Country:US
Mailing Address - Phone:331-806-6094
Mailing Address - Fax:
Practice Address - Street 1:319 S MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119-9119
Practice Address - Country:US
Practice Address - Phone:844-762-0735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty