Provider Demographics
NPI:1629481767
Name:CHAMPEAU, STACIE
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:
Last Name:CHAMPEAU
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 1:12795 FOUNTAIN SQ
Mailing Address - Street 2:
Mailing Address - City:DAVISBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48350-9991
Mailing Address - Country:US
Mailing Address - Phone:248-250-0140
Mailing Address - Fax:
Practice Address - Street 1:12795 FOUNTAIN SQ
Practice Address - Street 2:
Practice Address - City:DAVISBURG
Practice Address - State:MI
Practice Address - Zip Code:48350-9991
Practice Address - Country:US
Practice Address - Phone:248-250-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014143101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor