Provider Demographics
NPI:1619295169
Name:CHAMPAGNE, LEAH (LMT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 KELLOGG ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4376
Mailing Address - Country:US
Mailing Address - Phone:203-217-8969
Mailing Address - Fax:
Practice Address - Street 1:18 KELLOGG ST APT 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4376
Practice Address - Country:US
Practice Address - Phone:203-217-8969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4276225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist