Provider Demographics
NPI:1033578331
Name:CHAMPION STATE OF MIND PLLC
Entity Type:Organization
Organization Name:CHAMPION STATE OF MIND PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, NCC
Authorized Official - Phone:800-592-0180
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:ESTHERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51334-0036
Mailing Address - Country:US
Mailing Address - Phone:800-592-0180
Mailing Address - Fax:712-566-5229
Practice Address - Street 1:508 W CENTRAL AVE
Practice Address - Street 2:STE B
Practice Address - City:ESTHERVILLE
Practice Address - State:IA
Practice Address - Zip Code:51334-1834
Practice Address - Country:US
Practice Address - Phone:800-592-0180
Practice Address - Fax:712-566-5229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001653101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1033578331Medicaid