Provider Demographics
NPI:1164806618
Name:CHAMPAGNE, NICHOLE (MS)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53534 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-6356
Mailing Address - Country:US
Mailing Address - Phone:586-713-6566
Mailing Address - Fax:
Practice Address - Street 1:13213 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312
Practice Address - Country:US
Practice Address - Phone:586-939-4374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164806618Medicaid