Provider Demographics
NPI:1659633451
Name:CHAMPLIN, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CHAMPLIN
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 1:1300 QUARRY CT
Mailing Address - Street 2:STE. 115
Mailing Address - City:PT RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-4148
Mailing Address - Country:US
Mailing Address - Phone:510-684-2667
Mailing Address - Fax:
Practice Address - Street 1:27001 AGOURA RD
Practice Address - Street 2:STE. 210
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91301-5339
Practice Address - Country:US
Practice Address - Phone:877-371-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10842225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist