Provider Demographics
NPI:1265575542
Name:CHAMPION, CHERYL (LICSW)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4708
Mailing Address - Country:US
Mailing Address - Phone:763-427-7964
Mailing Address - Fax:763-427-7976
Practice Address - Street 1:1930 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4708
Practice Address - Country:US
Practice Address - Phone:763-427-7964
Practice Address - Fax:763-427-7976
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1265575542OtherBLUE CROSS BLUE SHIELD OF MINNESOTA
MN1265575542OtherMEDICARE
MN1265575542Medicaid
MN1265575542OtherMETROPOLITAN HEALTH PLAN
MN1265575542OtherHEALTH PARTNERS
MN1265575542OtherMEDICA (UBH)