Provider Demographics
NPI:1215172580
Name:CHAMPE, SANDRA R (PHD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:R
Last Name:CHAMPE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 W MAPLE RD
Mailing Address - Street 2:A-150
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3704
Mailing Address - Country:US
Mailing Address - Phone:248-339-6618
Mailing Address - Fax:866-607-5280
Practice Address - Street 1:5600 W MAPLE RD
Practice Address - Street 2:A-150
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3704
Practice Address - Country:US
Practice Address - Phone:248-339-6618
Practice Address - Fax:866-607-5280
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002806103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1332Medicare UPIN
MIMI1332Medicare PIN
MI1332Medicare PIN