Provider Demographics
NPI:1497348478
Name:CHAMPA, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:CHAMPA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 TAMARAC DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-2943
Mailing Address - Country:US
Mailing Address - Phone:847-857-1019
Mailing Address - Fax:
Practice Address - Street 1:155 N MICHIGAN AVE STE 202&723
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7511
Practice Address - Country:US
Practice Address - Phone:312-278-3054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490229971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical