Provider Demographics
NPI:1710311477
Name:CHAMPAGNE, BRIAN MICHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 KATALIN CT
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-2161
Mailing Address - Country:US
Mailing Address - Phone:989-439-1102
Mailing Address - Fax:989-439-1104
Practice Address - Street 1:3707 KATALIN CT
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2161
Practice Address - Country:US
Practice Address - Phone:989-439-1102
Practice Address - Fax:989-439-1104
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1997023225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant