Provider Demographics
NPI:1619075132
Name:ARCHIBONG, JAMES E (MSW PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:ARCHIBONG
Suffix:
Gender:M
Credentials:MSW PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E LAKE AVE
Mailing Address - Street 2:APT 1E
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3100
Mailing Address - Country:US
Mailing Address - Phone:443-847-6878
Mailing Address - Fax:410-233-6201
Practice Address - Street 1:2300 GARRISON BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2335
Practice Address - Country:US
Practice Address - Phone:410-233-6200
Practice Address - Fax:410-233-6201
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD094251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical