MEDICARE: DR. CAROLYN SUZETTE CHAMPION EDD CADC THD

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	20997	IL

General Provider Information

NPI Number	:	1467089573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROLYN SUZETTE CHAMPION EDD CADC THD

Provider Business Mailing Address
First Line	:	9105 S HARPER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-7917
Country	:	US
Telephone Number	:	773-550-5591
Fax Number	:

Provider Business Practice Location Address
First Line	:	2215 W 95TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-1001
Country	:	US
Telephone Number	:	773-819-0646
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2020
Last Update Date	:	03/26/2020

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