Healthcare Provider Details

I. General information

NPI: 1497348478
Provider Name (Legal Business Name): EMILY CHAMPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N MICHIGAN AVE STE 202&723
CHICAGO IL
60601-7511
US

IV. Provider business mailing address

825 TAMARAC DR
ALGONQUIN IL
60102-2943
US

V. Phone/Fax

Practice location:
  • Phone: 312-278-3054
  • Fax:
Mailing address:
  • Phone: 847-857-1019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149022997
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: