Healthcare Provider Details

I. General information

NPI: 1548526049
Provider Name (Legal Business Name): SHELLY DENISE CHAMPAGNE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ANDREA ST STE 205
BOWLING GREEN KY
42104-3382
US

IV. Provider business mailing address

104 REYNOLDS RD
GLASGOW KY
42141-1177
US

V. Phone/Fax

Practice location:
  • Phone: 270-205-4585
  • Fax: 270-936-7333
Mailing address:
  • Phone: 270-904-6567
  • Fax: 270-904-6570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3040
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: