MEDICARE: MARY CHAMPION

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	LMFT96596	CA
2	103TS0200X	School Psychologist	LEP4613	CA

General Provider Information

NPI Number	:	1457248916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY CHAMPION

Provider Business Mailing Address
First Line	:	2209 MIDWAY DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4956
Country	:	US
Telephone Number	:	858-736-5362
Fax Number	:

Provider Business Practice Location Address
First Line	:	5340 SKYLANE BLVD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-8246
Country	:	US
Telephone Number	:	707-524-2711
Fax Number	:

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

Provider Enumeration Date	:	06/18/2025
Last Update Date	:	06/18/2025

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Directions to “ MARY CHAMPION ” Practice Location

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