Provider Demographics
NPI:1104228709
Name:CHAMPLIN, MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CHAMPLIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:404 CAMINO DEL RIO S STE 508
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3503
Mailing Address - Country:US
Mailing Address - Phone:619-285-1002
Mailing Address - Fax:
Practice Address - Street 1:404 CAMINO DEL RIO S STE 508
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3503
Practice Address - Country:US
Practice Address - Phone:619-285-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT1877225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant