MEDICARE: CONNIE RAE CHAMPION LSW, LPC-IT, SAC-IT

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	101YP2500X	Professional Counselor	3265	WI
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	18546	WI

General Provider Information

NPI Number	:	1598253890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE RAE CHAMPION LSW, LPC-IT, SAC-IT

Provider Business Mailing Address
First Line	:	5900 MONONA DR STE 300
Second Line	:
City	:	MONONA
State	:	WI
Zip	:	53716-3561
Country	:	US
Telephone Number	:	608-663-2120
Fax Number	:

Provider Business Practice Location Address
First Line	:	414 BROADWAY ST STE 101
Second Line	:
City	:	BARABOO
State	:	WI
Zip	:	53913-2488
Country	:	US
Telephone Number	:	608-402-4312
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2018
Last Update Date	:	04/23/2018

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