Individual
SOPHIE CHAMPAGNE BLACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
310 AUTUMN RIDGE DR, KOSCIUSKO, MS 39090-3242
(662) 289-3499
Mailing address
4109 HIGHWAY 98 W, SUMMIT, MS 39666-9132
(601) 276-3900
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OT0533
MS
Other
Enumeration date
05/10/2007
Last updated
12/29/2009
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