Provider Demographics
NPI:1093246241
Name:ARCHILLA, VIVIAN (SLP)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:ARCHILLA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 OAK RIVER CIR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7229
Mailing Address - Country:US
Mailing Address - Phone:727-641-6033
Mailing Address - Fax:
Practice Address - Street 1:3117 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5632
Practice Address - Country:US
Practice Address - Phone:813-662-1106
Practice Address - Fax:813-661-7661
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14918235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist