Provider Demographics
NPI:1407911985
Name:ARCHER, MARY D (EDS, LCPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:D
Last Name:ARCHER
Suffix:
Gender:F
Credentials:EDS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 W CENTRAL AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6800
Mailing Address - Country:US
Mailing Address - Phone:406-544-8966
Mailing Address - Fax:
Practice Address - Street 1:725 W CENTRAL AVE STE 210
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6800
Practice Address - Country:US
Practice Address - Phone:406-544-8966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1090101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0256088Medicaid