MEDICARE: MS. LAURA CHAMPION LMFC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	32358	CA

General Provider Information

NPI Number	:	1255499505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA CHAMPION LMFC

Provider Business Mailing Address
First Line	:	251 LLEWELLYN AVE
Second Line	:
City	:	CAMPBELL
State	:	CA
Zip	:	95008-1940
Country	:	US
Telephone Number	:	408-364-4129
Fax Number	:	408-364-4013

Provider Business Practice Location Address
First Line	:	1073 IDLEWOOD DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95121-2720
Country	:	US
Telephone Number	:	408-578-2465
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/08/2007

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