MEDICARE: DOUGLAS ALLEN KIRK LCSW

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	1041C0700X	Clinical Social Worker	7093-123	WI

General Provider Information

NPI Number	:	1962516187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS ALLEN KIRK LCSW

Provider Business Mailing Address
First Line	:	1602 WICKLOW WAY
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53711-3665
Country	:	US
Telephone Number	:	608-280-7195
Fax Number	:	608-256-0743

Provider Business Practice Location Address
First Line	:	306 N BROOKS ST
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53715-1002
Country	:	US
Telephone Number	:	608-280-7195
Fax Number	:	608-256-0743

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	07/08/2007

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