Provider Demographics
NPI:1053686535
Name:ARCHER, ANITA
Entity type:Individual
Prefix:MS
First Name:ANITA
Middle Name:
Last Name:ARCHER
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:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64802-0426
Mailing Address - Country:US
Mailing Address - Phone:417-680-0777
Mailing Address - Fax:417-313-0754
Practice Address - Street 1:420 GRAND AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-2027
Practice Address - Country:US
Practice Address - Phone:417-680-0777
Practice Address - Fax:417-313-0754
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020012497103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO730083175Medicaid