Provider Demographics
NPI:1568493500
Name:DAUT, RANDALL L (PHD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:DAUT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MCMILLEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1263
Mailing Address - Country:US
Mailing Address - Phone:920-563-7995
Mailing Address - Fax:920-568-6047
Practice Address - Street 1:509 MCMILLEN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1263
Practice Address - Country:US
Practice Address - Phone:920-563-7995
Practice Address - Fax:920-568-6047
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI801-057103T00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39025900Medicaid
R59283Medicare UPIN