Provider Demographics
NPI:1114332434
Name:CHAMPAGNE, SHELBY (MSW INTERN)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:MSW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 MANSFIELD AVE
Mailing Address - Street 2:YAS SUITE
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226
Mailing Address - Country:US
Mailing Address - Phone:860-456-2261
Mailing Address - Fax:
Practice Address - Street 1:1007 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-2170
Practice Address - Country:US
Practice Address - Phone:860-774-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT97091041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical