Healthcare Provider Details

I. General information

NPI: 1013974849
Provider Name (Legal Business Name): KENOSHA ACHIEVEMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 79TH ST
KENOSHA WI
53143-6111
US

IV. Provider business mailing address

1218 79TH ST
KENOSHA WI
53143-6111
US

V. Phone/Fax

Practice location:
  • Phone: 262-658-9500
  • Fax: 262-658-9621
Mailing address:
  • Phone: 262-658-9500
  • Fax: 262-658-9621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. CHRISTINE WEYKER
Title or Position: DIRECTOR
Credential:
Phone: 262-658-9650