Provider Demographics
NPI:1942573308
Name:CHAMPION, FORREST JOSHUA
Entity Type:Individual
Prefix:MR
First Name:FORREST
Middle Name:JOSHUA
Last Name:CHAMPION
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6902 NW 37TH ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-3323
Mailing Address - Country:US
Mailing Address - Phone:405-570-0319
Mailing Address - Fax:
Practice Address - Street 1:7777 E US HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-9125
Practice Address - Country:US
Practice Address - Phone:405-422-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health