Provider Demographics
NPI:1659685196
Name:CHAMPAGNE, CASSIE DENISE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CASSIE
Middle Name:DENISE
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:CASSIE
Other - Middle Name:DENISE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1429 SOUTHERN OAKS DR.
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70665-7946
Mailing Address - Country:US
Mailing Address - Phone:337-304-4820
Mailing Address - Fax:337-583-4068
Practice Address - Street 1:601 DR. MICHAEL DEBAKEY DR.
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5726
Practice Address - Country:US
Practice Address - Phone:337-304-4820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4672-01171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor