Basic Information
| Provider Information | |||||||||
| NPI: | 1073091153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARCHAMBAULT | ||||||||
| FirstName: | AILEEN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015339104 | ||||||||
| FaxNumber: | 4015339105 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 HOWELL ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029061614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133473936 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2018 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0614 | 01 | RI | NHPRI | OTHER | SB870 | 01 | RI | BLUE CROSS | OTHER | EO1788 | 05 | RI | MEDICAID |