Provider Demographics
NPI:1568031417
Name:CHAMPAGNE, MARY K
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:CHAMPAGNE
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 1:57 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02466-1709
Mailing Address - Country:US
Mailing Address - Phone:518-578-6483
Mailing Address - Fax:
Practice Address - Street 1:109 OAK ST STE G30
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1492
Practice Address - Country:US
Practice Address - Phone:518-578-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2025-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA100000563103K00000X
MALABA100000563103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst