Provider Demographics
NPI:1215571658
Name:KOPALD, WENDY (LCSW)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:KOPALD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 RIDGE AVE STE 200-C
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5918
Mailing Address - Country:US
Mailing Address - Phone:847-677-5611
Mailing Address - Fax:
Practice Address - Street 1:1740 RIDGE AVE STE 200-C
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5918
Practice Address - Country:US
Practice Address - Phone:847-677-5611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14-0016721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical