Healthcare Provider Details

I. General information

NPI: 1104833284
Provider Name (Legal Business Name): LARRY DALE ARCHER CLINICAL PSYCHOLOGIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EVANSVILLE VA HEALTH CARE CENTER 6211 E. WATERFORD BLVD.
EVANSVILLE IN
47715
US

IV. Provider business mailing address

722 MELS DR
EVANSVILLE IN
47712-9632
US

V. Phone/Fax

Practice location:
  • Phone: 812-465-6202
  • Fax:
Mailing address:
  • Phone: 317-348-5752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20040417A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: