Provider Demographics
NPI:1356473367
Name:ARCHER, JOEL C
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:C
Last Name:ARCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 NYE RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489
Mailing Address - Country:US
Mailing Address - Phone:315-946-7066
Mailing Address - Fax:
Practice Address - Street 1:WAYNE BEHAVIORAL HEALTH NETWORK
Practice Address - Street 2:1519 NYE RD
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489
Practice Address - Country:US
Practice Address - Phone:315-946-7066
Practice Address - Fax:315-946-7066
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0725021104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07300072502Medicaid
NY07300072502Medicaid