Provider Demographics
NPI:1598253890
Name:CHAMPION, CONNIE RAE (LSW, LPC-IT, SAC-IT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:RAE
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:LSW, LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:RAE
Other - Last Name:GEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5900 MONONA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3561
Mailing Address - Country:US
Mailing Address - Phone:608-663-2120
Mailing Address - Fax:
Practice Address - Street 1:414 BROADWAY ST STE 101
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2488
Practice Address - Country:US
Practice Address - Phone:608-402-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3265101YP2500X
WI18546101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional