Provider Demographics
NPI:1023759545
Name:CHAMPAGNE, MOLLY MICHELE (LMT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:MICHELE
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:MICHELE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:281 HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-1664
Mailing Address - Country:US
Mailing Address - Phone:315-813-2313
Mailing Address - Fax:
Practice Address - Street 1:350 ALBERTA DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1855
Practice Address - Country:US
Practice Address - Phone:315-813-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031414225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist