=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679687727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDALL JAMES CHIPMAN LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 OVERLOOK TER BLDG. 7
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53705-2254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-280-7073
-----------------------------------------------------
Fax | 608-280-7296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6506 ASPEN CT
-----------------------------------------------------
City | WAUNAKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53597-9756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-846-3291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6556-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------