Basic Information
| Provider Information | |||||||||
| NPI: | 1861678989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARCHIE | ||||||||
| FirstName: | CAROL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4421 W 63RD ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900433513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238981160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 269 S MARIPOSA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900045407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136392696 | ||||||||
| FaxNumber: | 2133891987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2008 | ||||||||
| LastUpdateDate: | 01/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.