MEDICARE: DR. RANDALL WADE KRUPSAW PH.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	20040117A	IN

General Provider Information

NPI Number	:	1851567804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL WADE KRUPSAW PH.D.

Provider Business Mailing Address
First Line	:	8945 N MERIDIAN ST
Second Line	:	SUITE 125
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-5387
Country	:	US
Telephone Number	:	317-816-5600
Fax Number	:	317-815-5975

Provider Business Practice Location Address
First Line	:	8945 N MERIDIAN ST
Second Line	:	SUITE 125
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-5387
Country	:	US
Telephone Number	:	317-816-5600
Fax Number	:	317-815-5975

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

Provider Enumeration Date	:	04/30/2008
Last Update Date	:	04/30/2008

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