=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467089573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYN SUZETTE CHAMPION EDD CADC THD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2020
-----------------------------------------------------
Last Update Date | 03/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2215 W 95TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-819-0646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9105 S HARPER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60619-7917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-550-5591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 20997
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------