Provider Demographics
NPI:1346255817
Name:AMY SPRAGUE CHAMPEAU MS, LMFT
Entity Type:Organization
Organization Name:AMY SPRAGUE CHAMPEAU MS, LMFT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:SPRAGUE
Authorized Official - Last Name:CHAMPEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT
Authorized Official - Phone:262-635-9355
Mailing Address - Street 1:102 10TH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1513
Mailing Address - Country:US
Mailing Address - Phone:262-635-9355
Mailing Address - Fax:
Practice Address - Street 1:102 10TH ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1513
Practice Address - Country:US
Practice Address - Phone:262-635-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI552-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========016OtherBLUE CROSS