Provider Demographics
NPI:1144203936
Name:CHAMPEAU, MICHAEL LEO (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEO
Last Name:CHAMPEAU
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 19TH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2314
Mailing Address - Country:US
Mailing Address - Phone:262-637-8888
Mailing Address - Fax:262-637-0695
Practice Address - Street 1:2711 19TH ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2314
Practice Address - Country:US
Practice Address - Phone:262-637-8888
Practice Address - Fax:262-637-0695
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1106123106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39550300Medicaid
P33762Medicare UPIN