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General NPI Number Information
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NPI Number | 1538354998
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Entity Type | Individual
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Provider Name | KELLY M CHAMPION PH.D.
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Gender | Female
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Dates
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Enumeration Date | 09/10/2007
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Last Update Date | 05/28/2020
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Provider Practice Location Address
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Address Line | 4820 MORTENSEN ROAD SUITE 102
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City | AMES
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State | IA
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Zip | 50014-5531
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Country | US
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Telephone | 781-552-6500
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Fax | 888-859-4941
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Provider Business Mailing Address
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Address Line | 4820 MORTENSEN ROAD SUITE 102
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City | AMES
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State | IA
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Zip | 50014-5531
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Country | US
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Telephone | 781-552-6500
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Fax | 888-859-4941
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 8774
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 07388
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License Number State | IA
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 8774
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License Number State | MA
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Taxonomy #4
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 07388
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License Number State | IA
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