=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659633451
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN CHAMPLIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2012
-----------------------------------------------------
Last Update Date | 06/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27001 AGOURA RD STE. 210
-----------------------------------------------------
City | CALABASAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-5339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-371-0069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 QUARRY CT STE. 115
-----------------------------------------------------
City | PT RICHMOND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94801-4148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-684-2667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 10842
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------