Provider Demographics
NPI:1164860698
Name:ARCHAMBAULT, CONNY
Entity Type:Individual
Prefix:MS
First Name:CONNY
Middle Name:
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 1:1330 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TENNESSEE RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37178-4003
Mailing Address - Country:US
Mailing Address - Phone:193-172-1331
Mailing Address - Fax:
Practice Address - Street 1:1330 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TENNESSEE RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37178-4003
Practice Address - Country:US
Practice Address - Phone:193-172-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor