MEDICARE: CHAR CHAMPION THERAPY

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	252Y00000X	Early Intervention Provider Agency	1248105	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	528649	OTHER	NY	NYS DEPARTMENT OF HEALTH BUREAU OF EARLY INTERVENTION

General Provider Information

NPI Number	:	1497115836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAR CHAMPION THERAPY

Provider Business Mailing Address
First Line	:	351 MARINE AVE
Second Line	:	17C
City	:	BROOKLYN
State	:	NY
Zip	:	11209-8055
Country	:	US
Telephone Number	:	212-810-7578
Fax Number	:

Provider Business Practice Location Address
First Line	:	351 MARINE AVE
Second Line	:	17C
City	:	BROOKLYN
State	:	NY
Zip	:	11209-8055
Country	:	US
Telephone Number	:	212-810-7578
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LYUBOV CHAR
Credential	:	M.S., ABA
Telephone Number	:	212-810-7578

Provider Enumeration Date	:	02/27/2016
Last Update Date	:	02/27/2016

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