Provider Demographics
NPI:1912653130
Name:CHAMPION, TERESA REYNOLDS (OT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:REYNOLDS
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:KAY
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1579 TEXAS PKWY
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1635
Mailing Address - Country:US
Mailing Address - Phone:850-797-2088
Mailing Address - Fax:
Practice Address - Street 1:910 BROOKMEADE DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-6056
Practice Address - Country:US
Practice Address - Phone:850-682-1903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT13323225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist