Provider Demographics
NPI:1750905295
Name:CHAMPION, THERESA (MA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:CHAMPION
Suffix:
Gender:
Credentials:MA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MCGINNIS
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:321 E OHIO ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3847
Mailing Address - Country:US
Mailing Address - Phone:906-226-5100
Mailing Address - Fax:
Practice Address - Street 1:321 E OHIO ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-3847
Practice Address - Country:US
Practice Address - Phone:906-226-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MI6401224368101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health