Provider Demographics
NPI:1093356727
Name:CHAMPAGNE, CAROLE (OT)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 KNEEN STREET EXT
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-3937
Mailing Address - Country:US
Mailing Address - Phone:203-274-0777
Mailing Address - Fax:
Practice Address - Street 1:6448 MAIN ST
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-2075
Practice Address - Country:US
Practice Address - Phone:203-268-6204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003012225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist