Provider Demographics
NPI:1508177734
Name:BOUCEK, ROBERT JOSEPH JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:BOUCEK
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2506 GALEN DRIVE
Mailing Address - Street 2:#103
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-7047
Mailing Address - Country:US
Mailing Address - Phone:217-398-0744
Mailing Address - Fax:217-398-0778
Practice Address - Street 1:2506 GALEN DR
Practice Address - Street 2:#103
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-7046
Practice Address - Country:US
Practice Address - Phone:217-398-0744
Practice Address - Fax:217-398-0778
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008794103TC0700X
CAPSY23495103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical