Healthcare Provider Details

I. General information

NPI: 1063784304
Provider Name (Legal Business Name): CHAMPION & CHAMPION PA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 N DUKE ST 602
DURHAM NC
27704-3048
US

IV. Provider business mailing address

PO BOX 1314
CHAPEL HILL NC
27514-1314
US

V. Phone/Fax

Practice location:
  • Phone: 919-317-4088
  • Fax:
Mailing address:
  • Phone: 919-317-4088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number19912
License Number StateNC

VIII. Authorized Official

Name: DR. LAWRENCE CHAMPION
Title or Position: PRESIDENT
Credential: M.D.
Phone: 919-317-4088