Provider Demographics
NPI:1194882381
Name:CHAMPAGNE, BETH (DPT)
Entity type:Individual
Prefix:DR
First Name:BETH
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 WALDEN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1743
Mailing Address - Country:US
Mailing Address - Phone:617-388-8515
Mailing Address - Fax:
Practice Address - Street 1:206 WALDEN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1743
Practice Address - Country:US
Practice Address - Phone:617-388-8515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009015225100000X
MA16586225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist