Healthcare Provider Details

I. General information

NPI: 1144659236
Provider Name (Legal Business Name): NICOLE LYNN CHAMPAGNE BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE KOHAIF

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 03/14/2026
Certification Date: 03/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6627 ROSE ST
CASS CITY MI
48726
US

IV. Provider business mailing address

6627 ROSE ST
CASS CITY MI
48726-1262
US

V. Phone/Fax

Practice location:
  • Phone: 989-872-1800
  • Fax: 989-872-1801
Mailing address:
  • Phone: 989-872-1800
  • Fax: 989-872-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11313864
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: