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
State | License ID | Taxonomies |
---|---|---|
IL | 103K00000X, 103TB0200X, 103TC2200X, 174H00000X, 222Q00000X, 225X00000X, 225XF0002X, 225XR0403X, 235Z00000X | |
225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | Group - Multi-Specialty | |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
No | 174H00000X | Other Service Providers | Health Educator | Group - Multi-Specialty | |
No | 222Q00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 225XF0002X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Feeding, Eating & Swallowing | Group - Multi-Specialty |
No | 225XR0403X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Driving and Community Mobility | Group - Multi-Specialty |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty |