Provider Demographics
NPI:1528594611
Name:CHAMPAGNE, KATHRYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 N CLAREMONT AVE APT 110
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5375
Mailing Address - Country:US
Mailing Address - Phone:989-709-6328
Mailing Address - Fax:
Practice Address - Street 1:6959 W 64TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638
Practice Address - Country:US
Practice Address - Phone:708-257-4696
Practice Address - Fax:773-912-6954
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.011860225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist