MEDICARE: CHAMPION STATE OF MIND PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	001653	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033578331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAMPION STATE OF MIND PLLC

Provider Business Mailing Address
First Line	:	PO BOX 36
Second Line	:
City	:	ESTHERVILLE
State	:	IA
Zip	:	51334-0036
Country	:	US
Telephone Number	:	800-592-0180
Fax Number	:	712-566-5229

Provider Business Practice Location Address
First Line	:	508 W CENTRAL AVE
Second Line	:	STE B
City	:	ESTHERVILLE
State	:	IA
Zip	:	51334-1834
Country	:	US
Telephone Number	:	800-592-0180
Fax Number	:	712-566-5229

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. AMANDA OLSON
Credential	:	LMHC, NCC
Telephone Number	:	800-592-0180

Provider Enumeration Date	:	02/15/2016
Last Update Date	:	09/11/2018

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