Provider Demographics
NPI:1710347455
Name:CHAMPAGNE, MARIETTE (LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:MARIETTE
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 REVERE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 REVERE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1563
Practice Address - Country:US
Practice Address - Phone:847-650-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL31532101YA0400X
IL1490179471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)