Basic Information
| Provider Information | |||||||||
| NPI: | 1235322314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAMPAGNE | ||||||||
| FirstName: | HELEN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2415 CARR ST | ||||||||
| Address2: | |||||||||
| City: | PALATKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321774209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319942667 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 KAY LARKIN DR | ||||||||
| Address2: | |||||||||
| City: | PALATKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321772300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3863250173 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2007 | ||||||||
| LastUpdateDate: | 02/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 19072 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 28496 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.