Provider Demographics
NPI:1033794896
Name:DEGRACE, CHAMPAGNE (LMT)
Entity Type:Individual
Prefix:
First Name:CHAMPAGNE
Middle Name:
Last Name:DEGRACE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 GLENNON ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-5238
Mailing Address - Country:US
Mailing Address - Phone:774-400-0453
Mailing Address - Fax:
Practice Address - Street 1:114 GLENNON ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02745-5238
Practice Address - Country:US
Practice Address - Phone:774-400-0453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT02542225700000X
MA16094225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist