Provider Demographics
NPI:1194144956
Name:ARCHIE, EVA
Entity type:Individual
Prefix:
First Name:EVA
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 1:3934 DIXIE HWY
Mailing Address - Street 2:STE 330
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-4170
Mailing Address - Country:US
Mailing Address - Phone:502-409-4357
Mailing Address - Fax:502-409-4357
Practice Address - Street 1:3934 DIXIE HWY STE 330
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4170
Practice Address - Country:US
Practice Address - Phone:502-409-4357
Practice Address - Fax:502-873-5048
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY164871101YA0400X
106H00000X, 251S00000X
MI4101007322106H00000X
KY175T00000X
KY162990106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100381410Medicaid