Provider Demographics
NPI:1538354998
Name:CHAMPION, KELLY M (PHD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 MORTENSEN ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-5531
Mailing Address - Country:US
Mailing Address - Phone:781-552-6500
Mailing Address - Fax:888-859-4941
Practice Address - Street 1:4820 MORTENSEN ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-5531
Practice Address - Country:US
Practice Address - Phone:781-552-6500
Practice Address - Fax:888-859-4941
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8774103TC2200X, 103TC0700X
IA07388103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSOCIAL