Provider Demographics
NPI:1942700547
Name:RANDERSON, CRAIG ROBERT (MSW, CAPSW)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ROBERT
Last Name:RANDERSON
Suffix:
Gender:M
Credentials:MSW, CAPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3986 CONRAD ST
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:WI
Mailing Address - Zip Code:54130-7527
Mailing Address - Country:US
Mailing Address - Phone:920-419-4835
Mailing Address - Fax:
Practice Address - Street 1:150 W 1ST ST STE 270
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1770
Practice Address - Country:US
Practice Address - Phone:715-246-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130965-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical