Provider Demographics
NPI:1760155519
Name:DUMPPROPE, CHANNA KAY (BS, LADC)
Entity Type:Individual
Prefix:
First Name:CHANNA
Middle Name:KAY
Last Name:DUMPPROPE
Suffix:
Gender:F
Credentials:BS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 2ND ST SW STE 1
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1483
Mailing Address - Country:US
Mailing Address - Phone:218-631-1714
Mailing Address - Fax:218-249-1506
Practice Address - Street 1:11 2ND ST SW STE 1
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1483
Practice Address - Country:US
Practice Address - Phone:218-631-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304925101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty