Provider Demographics
NPI:1104833284
Name:ARCHER, LARRY DALE (CLINICAL PSYCHOLOGIS)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DALE
Last Name:ARCHER
Suffix:
Gender:M
Credentials:CLINICAL PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 MELS DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-9632
Mailing Address - Country:US
Mailing Address - Phone:317-348-5752
Mailing Address - Fax:
Practice Address - Street 1:EVANSVILLE VA HEALTH CARE CENTER
Practice Address - Street 2:6211 E. WATERFORD BLVD.
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715
Practice Address - Country:US
Practice Address - Phone:812-465-6202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040417A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100254440BMedicaid
R34432Medicare UPIN
IN100254440BMedicaid