Provider Demographics
NPI:1760785620
Name:CHAMPAGNE, NICOLE NMI (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:NMI
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:BLDG. 1, 3RD FLOOR
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1208
Mailing Address - Country:US
Mailing Address - Phone:619-532-8858
Mailing Address - Fax:619-532-3501
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:BLDG. 1, 3RD FLOOR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1208
Practice Address - Country:US
Practice Address - Phone:619-532-8858
Practice Address - Fax:619-532-3501
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 25014104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker