Provider Demographics
NPI:1215990197
Name:CHAMPA, HOLLY ANN (LMHC)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:CHAMPA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 MICHIGAN AVE
Mailing Address - Street 2:J 2
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-5758
Mailing Address - Country:US
Mailing Address - Phone:321-639-4483
Mailing Address - Fax:321-690-0848
Practice Address - Street 1:1970 MICHIGAN AVE
Practice Address - Street 2:J 2
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-5758
Practice Address - Country:US
Practice Address - Phone:321-639-4483
Practice Address - Fax:321-690-0848
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 6888101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ9402OtherBLUE CROSS BLUE SHIELD