MEDICARE: DR. ROBERT JOSEPH BOUCEK JR. PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071008794	IL
2	103TC0700X	Clinical Psychologist	PSY23495	CA

General Provider Information

NPI Number	:	1508177734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT JOSEPH BOUCEK JR. PSY.D.

Provider Business Mailing Address
First Line	:	2506 GALEN DRIVE
Second Line	:	#103
City	:	CHAMPAIGN
State	:	IL
Zip	:	61821-7047
Country	:	US
Telephone Number	:	217-398-0744
Fax Number	:	217-398-0778

Provider Business Practice Location Address
First Line	:	2506 GALEN DR
Second Line	:	#103
City	:	CHAMPAIGN
State	:	IL
Zip	:	61821-7046
Country	:	US
Telephone Number	:	217-398-0744
Fax Number	:	217-398-0778

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2010
Last Update Date	:	05/01/2015

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