Provider Demographics
NPI:1508675745
Name:REFUGE, CHANNELLE LAVONNE (LMSW)
Entity type:Individual
Prefix:
First Name:CHANNELLE
Middle Name:LAVONNE
Last Name:REFUGE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5284 FLOYD RD SW UNIT 1929
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-6118
Mailing Address - Country:US
Mailing Address - Phone:812-987-1507
Mailing Address - Fax:
Practice Address - Street 1:86 COOPER LAKE RD SE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-1802
Practice Address - Country:US
Practice Address - Phone:770-284-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW011245104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker