Provider Demographics
NPI:1154989069
Name:CHAMPANHET, ELISE NOELLE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:NOELLE
Last Name:CHAMPANHET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6324 GREENLAND RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:KY
Mailing Address - Zip Code:41091-3402
Mailing Address - Country:US
Mailing Address - Phone:989-600-4610
Mailing Address - Fax:
Practice Address - Street 1:2207 WOODHAVENS DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7812
Practice Address - Country:US
Practice Address - Phone:312-561-6289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty