Provider Demographics
NPI:1447285044
Name:ARCHBOLD, MAIRE (OTR/L)
Entity type:Individual
Prefix:
First Name:MAIRE
Middle Name:
Last Name:ARCHBOLD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 14TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-5225
Mailing Address - Country:US
Mailing Address - Phone:727-327-3868
Mailing Address - Fax:727-327-3868
Practice Address - Street 1:4401 14TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-5225
Practice Address - Country:US
Practice Address - Phone:727-327-3868
Practice Address - Fax:727-327-3868
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29461225700000X
FLOT3198225XH1300X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225XH1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHuman Factors
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888349100Medicaid