Provider Demographics
NPI:1447089784
Name:CHAMPINE, MALORI CLARE
Entity type:Individual
Prefix:
First Name:MALORI
Middle Name:CLARE
Last Name:CHAMPINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3599 E SOUTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-8507
Mailing Address - Country:US
Mailing Address - Phone:989-364-2130
Mailing Address - Fax:
Practice Address - Street 1:203 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48607-1208
Practice Address - Country:US
Practice Address - Phone:989-209-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician