Provider Demographics
NPI:1871766949
Name:CHAMPION, STACEY
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:CHAMPION
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 1:3724 NATIONAL DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4070
Mailing Address - Country:US
Mailing Address - Phone:877-781-9565
Mailing Address - Fax:
Practice Address - Street 1:3724 NATIONAL DR
Practice Address - Street 2:SUITE 110
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4070
Practice Address - Country:US
Practice Address - Phone:877-781-9565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3393225XR0403X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility