Provider Demographics
NPI:1356685580
Name:CHAMP, MICHAEL W (LMHC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:CHAMP
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W LOWE AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-2470
Mailing Address - Country:US
Mailing Address - Phone:641-233-8332
Mailing Address - Fax:
Practice Address - Street 1:200 W LOWE AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-2470
Practice Address - Country:US
Practice Address - Phone:641-233-8332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2014-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001546101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health