Provider Demographics
NPI:1871183533
Name:CHAMPAGNE, THEODORE (MA)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:
Other - Last Name:CHAMPAGNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:308 SOLARIS WHARF ST
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-7107
Mailing Address - Country:US
Mailing Address - Phone:407-739-1728
Mailing Address - Fax:
Practice Address - Street 1:308 SOLARIS WHARF ST
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-7107
Practice Address - Country:US
Practice Address - Phone:407-739-1728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19626101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health