Provider Demographics
NPI:1861678989
Name:ARCHIE, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:ARCHIE
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 1:4421 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-3513
Mailing Address - Country:US
Mailing Address - Phone:323-898-1160
Mailing Address - Fax:
Practice Address - Street 1:269 S MARIPOSA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-5407
Practice Address - Country:US
Practice Address - Phone:213-639-2696
Practice Address - Fax:213-389-1987
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner