Provider Demographics
NPI:1952790560
Name:THE CHAMPION CENTER FOR AUTISM, INC
Entity Type:Organization
Organization Name:THE CHAMPION CENTER FOR AUTISM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LATRICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-213-7991
Mailing Address - Street 1:17500 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4884
Mailing Address - Country:US
Mailing Address - Phone:708-213-7991
Mailing Address - Fax:708-365-6765
Practice Address - Street 1:17500 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-4884
Practice Address - Country:US
Practice Address - Phone:708-213-7991
Practice Address - Fax:708-365-6765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X, 103TB0200X, 103TC2200X, 174H00000X, 222Q00000X, 225X00000X, 225XF0002X, 225XR0403X, 235Z00000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & SwallowingGroup - Multi-Specialty
No225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community MobilityGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty