Provider Demographics
NPI:1821469909
Name:CHAMPINE, MIRIAM R
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:R
Last Name:CHAMPINE
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 1:32715 DORSEY ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-4755
Mailing Address - Country:US
Mailing Address - Phone:734-641-1141
Mailing Address - Fax:
Practice Address - Street 1:32715 DORSEY ST
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-4755
Practice Address - Country:US
Practice Address - Phone:734-641-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016441103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling