Provider Demographics
NPI:1053814848
Name:CHILD AND FAMILY COUNSELING OF CHAMPAIGN LLC
Entity Type:Organization
Organization Name:CHILD AND FAMILY COUNSELING OF CHAMPAIGN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARILEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:242-232-8057
Mailing Address - Street 1:706 LAVENDER DR
Mailing Address - Street 2:
Mailing Address - City:SAVOY
Mailing Address - State:IL
Mailing Address - Zip Code:61874-9322
Mailing Address - Country:US
Mailing Address - Phone:224-326-1943
Mailing Address - Fax:
Practice Address - Street 1:313 N MATTIS AVE STE 116
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-7900
Practice Address - Country:US
Practice Address - Phone:224-232-8057
Practice Address - Fax:217-888-2744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-17
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010891101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty