Provider Demographics
NPI:1689138778
Name:ARCHIBONG, LCSW-C, EYAMBA
Entity Type:Individual
Prefix:
First Name:EYAMBA
Middle Name:
Last Name:ARCHIBONG, LCSW-C
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ECOWAY CT APT 1C
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-4436
Mailing Address - Country:US
Mailing Address - Phone:443-680-7083
Mailing Address - Fax:
Practice Address - Street 1:4308 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-3116
Practice Address - Country:US
Practice Address - Phone:667-205-1708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD180291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical