Provider Demographics
NPI:1114751690
Name:CHAMPAGNE, KEVIN J
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WATERSIDE XING STE 401
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1588
Mailing Address - Country:US
Mailing Address - Phone:860-697-3351
Mailing Address - Fax:860-731-5536
Practice Address - Street 1:207 BRAINARD RD
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-2102
Practice Address - Country:US
Practice Address - Phone:860-834-8765
Practice Address - Fax:860-761-7928
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT10971104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor