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1820 Central Ave Estherville IA 51334-2409 | |
| (712) 340-7323 | |
| (712) 560-9088 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 1820 Central Ave, Estherville, Iowa |
| Authorized Official Name and Position | Amanda Jade Olson (OWNER & CEO) |
| Authorized Official Contact | 7123407323 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 308 Estherville IA 51334-0308 Ph: (712) 340-7323 | 1820 Central Ave Estherville IA 51334-2409 Ph: (712) 340-7323 |
| NPI Number | 1609551787 |
|---|---|
| Provider Enumeration Date | 06/16/2023 |
| Last Update Date | 02/20/2024 |
| Certification Date | 02/20/2024 |
| Medicare PECOS PAC ID | 3971046897 |
|---|---|
| Medicare Enrollment ID | O20240620001656 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1609551787 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Secondary |
| Provider Name | Samantha Graham |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1073037420 PECOS PAC ID: 2264876986 Enrollment ID: I20240221000321 |
| Provider Name | Madison G Wagner |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1598379752 PECOS PAC ID: 2466894175 Enrollment ID: I20240528000730 |
| Provider Name | Amanda J Olson |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1558794099 PECOS PAC ID: 2163705898 Enrollment ID: I20240620001839 |
Champion State Of Mind Pllc Mental Health Clinic Medicare: Medicare Enrolled Practice Location: 508 W Central Ave, Ste B, Estherville, IA 51334 Phone: 800-592-0180 Fax: 712-566-5229 |