Provider Demographics
NPI:1427404219
Name:ARCHER, BRENT (MA)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:ARCHER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HEALTH AND HUMAN SERVICES
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43403-8550
Mailing Address - Country:US
Mailing Address - Phone:419-372-2515
Mailing Address - Fax:
Practice Address - Street 1:200 HEALTH AND HUMAN SERVICES
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43403-8550
Practice Address - Country:US
Practice Address - Phone:419-372-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7152235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist