Healthcare Provider Details

I. General information

NPI: 1043344146
Provider Name (Legal Business Name): BELL THERAPY CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 8TH AVE
KENOSHA WI
53140-3700
US

IV. Provider business mailing address

3324 COUNTY LINE RD
RACINE WI
53403-9704
US

V. Phone/Fax

Practice location:
  • Phone: 262-564-0067
  • Fax:
Mailing address:
  • Phone: 262-552-7311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number148570030
License Number StateWI

VIII. Authorized Official

Name: MRS. SHERILYN CATHERINE DE FAZIO
Title or Position: NURSE
Credential: RN
Phone: 262-564-0067