| Champion State Of Mind Pllc | |
|
508 W Central Ave Ste B Estherville IA 51334-1834 | |
| (800) 592-0180 | |
| (712) 566-5229 |
| Full Name | Champion State Of Mind Pllc |
|---|---|
| Speciality | Counselor |
| Location | 508 W Central Ave, Estherville, Iowa |
| Authorized Official Name and Position | Amanda Olson (OWNER) |
| Authorized Official Contact | 8005920180 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Champion State Of Mind Pllc Po Box 36 Estherville IA 51334-0036 Ph: (800) 592-0180 | Champion State Of Mind Pllc 508 W Central Ave Ste B Estherville IA 51334-1834 Ph: (800) 592-0180 |
| NPI Number | 1033578331 |
|---|---|
| Provider Enumeration Date | 02/15/2016 |
| Last Update Date | 09/11/2018 |
| Medicare PECOS PAC ID | 2860758372 |
|---|---|
| Medicare Enrollment ID | O20171115002508 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1033578331 | NPI | - | NPPES |
| 1033578331 | Medicaid | IA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | 001653 (Iowa) | Primary |
| Provider Name | Elizabeth Jean Jacobs |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1376059022 PECOS PAC ID: 9335522077 Enrollment ID: I20221029000192 |
Moxie Nova Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 1820 Central Ave, Estherville, IA 51334 Phone: 712-340-7323 Fax: 712-560-9088 |