Provider Demographics
NPI:1780183285
Name:ARCHERFAIR, KATINA
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:
Last Name:ARCHERFAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATINA
Other - Middle Name:
Other - Last Name:BALLARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAIDEN
Mailing Address - Street 1:2226 CRISTON DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-5102
Mailing Address - Country:US
Mailing Address - Phone:520-221-8810
Mailing Address - Fax:
Practice Address - Street 1:2226 CRISTON DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-5102
Practice Address - Country:US
Practice Address - Phone:520-221-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist