Healthcare Provider Details

I. General information

NPI: 1194630988
Provider Name (Legal Business Name): SHUKUNDALA CLARK CHAMPION DSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 170100
BYRAM MS
39272
US

IV. Provider business mailing address

PO BOX 170100
BYRAM MS
39272
US

V. Phone/Fax

Practice location:
  • Phone: 769-224-0839
  • Fax:
Mailing address:
  • Phone: 601-613-9965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC5540
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: