Healthcare Provider Details

I. General information

NPI: 1487719191
Provider Name (Legal Business Name): LAUREN D BOUCEK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN D. GROSS LCSW

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 W. KIRBY AVE
CHAMPAIGN IL
61821-5410
US

IV. Provider business mailing address

611 W. PARK ST. BWPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-1850
  • Fax: 217-383-3439
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23179
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149016829
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: