Provider Demographics
NPI:1932221090
Name:CHAMP, PATRICIA ANN (LMHC, LADC 1)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ANN
Last Name:CHAMP
Suffix:
Gender:F
Credentials:LMHC, LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-6330
Mailing Address - Country:US
Mailing Address - Phone:508-224-5668
Mailing Address - Fax:
Practice Address - Street 1:20 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:S YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02664-1814
Practice Address - Country:US
Practice Address - Phone:508-398-5155
Practice Address - Fax:508-398-3478
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4936 , 269101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)