Provider Demographics
NPI:1396411062
Name:CHAMPAGNE, CHERYL ANN (MS)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
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 1:36750 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-1239
Mailing Address - Country:US
Mailing Address - Phone:917-361-7201
Mailing Address - Fax:
Practice Address - Street 1:7623 LITTLE RD STE 300-325B
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-5570
Practice Address - Country:US
Practice Address - Phone:727-910-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22043101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health