Basic Information
| Provider Information | |||||||||
| NPI: | 1164673133 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOKUS FAMILY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 639 | ||||||||
| Address2: | |||||||||
| City: | THIENSVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530920639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142479005 | ||||||||
| FaxNumber: | 4142479004 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 N 4TH ST | ||||||||
| Address2: | SUITE 139 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532122362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142644217 | ||||||||
| FaxNumber: | 4142644218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2008 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | ELZORA | ||||||||
| AuthorizedOfficialMiddleName: | DARLENE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4142644217 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | BS,CSAC-ICS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 2473 | WI | N | Agencies | Community/Behavioral Health | 291U00000X | 52D2043078 | WI | N | Laboratories | Clinical Medical Laboratory | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 42247800 | 05 | WI | MEDICAID | 42247821 | 05 | WI | MEDICAID | WI2479 | 01 | MEDICARE PTAN | OTHER |