Provider Demographics
NPI:1568714707
Name:CHAMPAGNE, JEFFREY D (OTRL)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 HEMLOCK CT
Mailing Address - Street 2:
Mailing Address - City:NEWFIELDS
Mailing Address - State:NH
Mailing Address - Zip Code:03856-8306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 AUBURN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-4803
Practice Address - Country:US
Practice Address - Phone:603-623-8863
Practice Address - Fax:603-623-3461
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2233225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist