Basic Information
| Provider Information | |||||||||
| NPI: | 1578758413 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISCONSIN COMMUNITY SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3732 W. WISCONSIN AVENUE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532083166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142900400 | ||||||||
| FaxNumber: | 4142714605 | ||||||||
| Practice Location | |||||||||
| Address1: | 3734 W. WISCONSIN AVENUE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532083153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143446111 | ||||||||
| FaxNumber: | 4143442191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | PATZER | ||||||||
| AuthorizedOfficialFirstName: | HOLLIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4142900400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 43427500 | 05 | WI | MEDICAID |