Provider Demographics
NPI:1699483222
Name:SMITH, CHAMPAGNAE
Entity type:Individual
Prefix:
First Name:CHAMPAGNAE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8802 VALENCIA ROSE
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1675
Mailing Address - Country:US
Mailing Address - Phone:215-475-1327
Mailing Address - Fax:
Practice Address - Street 1:110 EVANS MILL DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-1622
Practice Address - Country:US
Practice Address - Phone:215-475-1327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health