Provider Demographics
NPI:1558818559
Name:ARCHIBALD, GRACE (OTR/L)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:ARCHIBALD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-2700
Mailing Address - Country:US
Mailing Address - Phone:203-757-9271
Mailing Address - Fax:
Practice Address - Street 1:128 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-2700
Practice Address - Country:US
Practice Address - Phone:203-757-9271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4666225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist