Healthcare Provider Details

I. General information

NPI: 1962516187
Provider Name (Legal Business Name): DOUGLAS ALLEN KIRK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 N BROOKS ST
MADISON WI
53715-1002
US

IV. Provider business mailing address

1602 WICKLOW WAY
MADISON WI
53711-3665
US

V. Phone/Fax

Practice location:
  • Phone: 608-280-7195
  • Fax: 608-256-0743
Mailing address:
  • Phone: 608-280-7195
  • Fax: 608-256-0743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7093-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: