Provider Demographics
NPI:1609383421
Name:CHAMPION, STEPHANIE ROSE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROSE
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 FIELDSTONE RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919
Mailing Address - Country:US
Mailing Address - Phone:719-203-6903
Mailing Address - Fax:719-203-6904
Practice Address - Street 1:2760 FIELDSTONE RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:80919
Practice Address - Country:US
Practice Address - Phone:719-203-6903
Practice Address - Fax:719-203-6904
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1225223126Medicaid