Provider Demographics
NPI:1932579505
Name:CHAMPION THERAPY
Entity Type:Organization
Organization Name:CHAMPION THERAPY
Other - Org Name:GLORIA RENEE TRAWEEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:TRAWEEK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:281-813-7894
Mailing Address - Street 1:268 ARGOSY LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-6858
Mailing Address - Country:US
Mailing Address - Phone:281-813-7894
Mailing Address - Fax:888-638-6067
Practice Address - Street 1:25435 FM 2978
Practice Address - Street 2:SUITE 108
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375
Practice Address - Country:US
Practice Address - Phone:281-813-7894
Practice Address - Fax:888-638-6067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32515251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB104149Medicare PIN