Provider Demographics
NPI:1114045614
Name:ARCHIE, VIRGINIA RUTH
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:RUTH
Last Name:ARCHIE
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 1:1502 E CARSON RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-5621
Mailing Address - Country:US
Mailing Address - Phone:602-276-7690
Mailing Address - Fax:
Practice Address - Street 1:1502 E CARSON RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-5621
Practice Address - Country:US
Practice Address - Phone:602-276-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1372385HR2055X
AS1372253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child