Provider Demographics
NPI:1851567804
Name:KRUPSAW, RANDALL WADE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WADE
Last Name:KRUPSAW
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 1:8945 N MERIDIAN ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5387
Mailing Address - Country:US
Mailing Address - Phone:317-816-5600
Mailing Address - Fax:317-815-5975
Practice Address - Street 1:8945 N MERIDIAN ST
Practice Address - Street 2:SUITE 125
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5387
Practice Address - Country:US
Practice Address - Phone:317-816-5600
Practice Address - Fax:317-815-5975
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040117A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical