Provider Demographics
NPI:1932111341
Name:CHAMPAGNE, KRISTINE ROOP (LICSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:ROOP
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 NW MARKET ST
Mailing Address - Street 2:SUITE 412
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4030
Mailing Address - Country:US
Mailing Address - Phone:206-501-4059
Mailing Address - Fax:
Practice Address - Street 1:2208 NW MARKET ST
Practice Address - Street 2:SUITE 412
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4030
Practice Address - Country:US
Practice Address - Phone:206-501-4059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1007741041C0700X
WALW600122161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1852388Medicaid
WA5776242OtherAETNA
MA1892967OtherMBHP
WA6A849OtherPREMERA
WA1000246OtherCIGNA
MAP02025OtherBLUE CROSS BLUE SHIELD
MA761512OtherTUFTS HEALTH PLANS
MA761512OtherTUFTS HEALTH PLANS