Healthcare Provider Details

I. General information

NPI: 1144203936
Provider Name (Legal Business Name): MICHAEL LEO CHAMPEAU LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 19TH ST
RACINE WI
53403-2314
US

IV. Provider business mailing address

2711 19TH ST
RACINE WI
53403-2314
US

V. Phone/Fax

Practice location:
  • Phone: 262-637-8888
  • Fax: 262-637-0695
Mailing address:
  • Phone: 262-637-8888
  • Fax: 262-637-0695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1106123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: