MEDICARE: SANDRA S CHAMPA LCSW CAP LLC

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	1041C0700X	Clinical Social Worker	SW8305	FL

General Provider Information

NPI Number	:	1356758536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDRA S CHAMPA LCSW CAP LLC

Provider Business Mailing Address
First Line	:	7437 PINE PARK DR S
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-8852
Country	:	US
Telephone Number	:	561-929-3792
Fax Number	:	954-785-5808

Provider Business Practice Location Address
First Line	:	1825 FOREST HILL BLVD STE 105
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-6058
Country	:	US
Telephone Number	:	561-929-3792
Fax Number	:	954-785-5808

Authorized Official
Title or Position	:	MEDICAL BILLER
Name	:	TERRI HIRSCHBERG
Credential	:
Telephone Number	:	954-784-2845

Provider Enumeration Date	:	07/19/2014
Last Update Date	:	03/12/2021

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