Provider Demographics
NPI:1083908776
Name:CHAMPAGNE, KIM (CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:KIM
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3106 QUARRY PLACE LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-1796
Mailing Address - Country:US
Mailing Address - Phone:337-344-5654
Mailing Address - Fax:
Practice Address - Street 1:3106 QUARRY PLACE LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77493-1796
Practice Address - Country:US
Practice Address - Phone:337-344-5654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105548235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist