Provider Demographics
NPI:1164011722
Name:KOPCHA, PETER (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:KOPCHA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4542 MATTIS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3072
Mailing Address - Country:US
Mailing Address - Phone:314-952-2947
Mailing Address - Fax:
Practice Address - Street 1:5151 MATTIS RD STE C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2796
Practice Address - Country:US
Practice Address - Phone:314-952-2947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-02-24
Deactivation Date:2021-01-22
Deactivation Code:
Reactivation Date:2021-02-24
Provider Licenses
StateLicense IDTaxonomies
MO20200426801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical