Provider Demographics
NPI:1164730776
Name:BRANDELL-CHAMPAGNE, KATHLEEN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:BRANDELL-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 1:126 LIGHTHOUSE ROAD
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-569-5660
Mailing Address - Fax:
Practice Address - Street 1:37 EAGLE WAY
Practice Address - Street 2:
Practice Address - City:WEST CHAZY
Practice Address - State:NY
Practice Address - Zip Code:12992
Practice Address - Country:US
Practice Address - Phone:518-563-8035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58010723235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY58010723OtherNEW YORK STATE LICENSE NUMBER