Provider Demographics
NPI:1326786609
Name:CHAMPION, CHANDLER
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:CHAMPION
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5221 WILHELM WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINBURG
Mailing Address - State:AR
Mailing Address - Zip Code:72946-3292
Mailing Address - Country:US
Mailing Address - Phone:479-629-1585
Mailing Address - Fax:
Practice Address - Street 1:1109 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-3363
Practice Address - Country:US
Practice Address - Phone:479-474-6444
Practice Address - Fax:479-474-6446
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician