Provider Demographics
NPI:1073245940
Name:CHAMPAGNE, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:CHAMPAGNE
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 1:4 W HILL DR
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-1933
Mailing Address - Country:US
Mailing Address - Phone:401-578-8087
Mailing Address - Fax:
Practice Address - Street 1:400 BALD HILL RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1617
Practice Address - Country:US
Practice Address - Phone:401-349-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent