Provider Demographics
NPI:1073276689
Name:ARCHER, KAYLYNN MAGE
Entity Type:Individual
Prefix:
First Name:KAYLYNN
Middle Name:MAGE
Last Name:ARCHER
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 1:1161 N FALCON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-3393
Mailing Address - Country:US
Mailing Address - Phone:520-256-3455
Mailing Address - Fax:
Practice Address - Street 1:4501 N CAMINO DEL OBISPO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6605
Practice Address - Country:US
Practice Address - Phone:520-256-3455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician