Healthcare Provider Details

I. General information

NPI: 1164011722
Provider Name (Legal Business Name): PETER KOPCHA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date: 01/22/2021
Reactivation Date: 02/24/2021

III. Provider practice location address

5151 MATTIS RD STE C
SAINT LOUIS MO
63128-2796
US

IV. Provider business mailing address

4542 MATTIS RD
SAINT LOUIS MO
63128-3072
US

V. Phone/Fax

Practice location:
  • Phone: 314-952-2947
  • Fax:
Mailing address:
  • Phone: 314-952-2947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2020042680
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: