Healthcare Provider Details

I. General information

NPI: 1770265977
Provider Name (Legal Business Name): SOLOLEYA TEKLEHAIMANOT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N RANDOLPH ST STE 2
CHAMPAIGN IL
61820-3976
US

IV. Provider business mailing address

PO BOX 24449
NEW YORK NY
10087-0589
US

V. Phone/Fax

Practice location:
  • Phone: 833-351-8255
  • Fax:
Mailing address:
  • Phone: 833-351-8255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801120911
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberTPSW7212
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149041072
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: