Provider Demographics
NPI:1073091153
Name:ARCHAMBAULT, AILEEN JAMES
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:JAMES
Last Name:ARCHAMBAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4739
Mailing Address - Country:US
Mailing Address - Phone:401-533-9104
Mailing Address - Fax:401-533-9105
Practice Address - Street 1:220 HOWELL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-1614
Practice Address - Country:US
Practice Address - Phone:413-347-3936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0614OtherNHPRI
RISB870OtherBLUE CROSS
RIEO1788Medicaid