Provider Demographics
NPI:1609573955
Name:CHAMPAGNE, CODY DON (LMT)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:DON
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 SHERMAN ST APT 216
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1066
Mailing Address - Country:US
Mailing Address - Phone:817-994-4444
Mailing Address - Fax:
Practice Address - Street 1:2718 SHERMAN ST APT 216
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1066
Practice Address - Country:US
Practice Address - Phone:817-994-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT135288225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist