Healthcare Provider Details

I. General information

NPI: 1073091153
Provider Name (Legal Business Name): AILEEN JAMES ARCHAMBAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 HOWELL ST
PROVIDENCE RI
02906-1614
US

IV. Provider business mailing address

1000 EDDY ST
PROVIDENCE RI
02905-4739
US

V. Phone/Fax

Practice location:
  • Phone: 413-347-3936
  • Fax:
Mailing address:
  • Phone: 401-533-9104
  • Fax: 401-533-9105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: