Provider Demographics
NPI:1174516991
Name:KOUPAL, ROBERT (LCSW)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:KOUPAL
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 1:2102 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1135
Mailing Address - Country:US
Mailing Address - Phone:563-359-4049
Mailing Address - Fax:
Practice Address - Street 1:2102 E 38TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1135
Practice Address - Country:US
Practice Address - Phone:563-359-4049
Practice Address - Fax:563-359-4069
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490060721041C0700X
IA005291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL99862OtherBLUE CROSS IOWA IL NUMBER
IA34752OtherBLUE CROSS IOWA IA NUMBER
IL2216745OtherFIRST HEALTH AND CCN NUMB
IL0582221Medicaid
ILIL0199OtherJOHN DEERE NUMBER
IL149006072OtherBLUE CROSS ILLINOIS NUMBE
IL1582221Medicaid
ILIL0199OtherJOHN DEERE NUMBER
ILP00134171Medicare ID - Type UnspecifiedRR MEDICARE NUMBER
IL0582221Medicaid