Provider Demographics
NPI:1467089573
Name:CHAMPION, CAROLYN SUZETTE (EDD CADC THD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:SUZETTE
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:EDD CADC THD
Other - Prefix:
Other - First Name:MOKL
Other - Middle Name:MOKL
Other - Last Name:MOKL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD CADC THD
Mailing Address - Street 1:9105 S HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-7917
Mailing Address - Country:US
Mailing Address - Phone:773-550-5591
Mailing Address - Fax:
Practice Address - Street 1:2215 W 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1001
Practice Address - Country:US
Practice Address - Phone:773-819-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20997101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health