Healthcare Provider Details

I. General information

NPI: 1497951925
Provider Name (Legal Business Name): BELL THERAPY KENOSHA COMMUNITY SUPPORT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
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

5500 8TH AVE
KENOSHA WI
53140-3700
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number2409
License Number StateWI

VIII. Authorized Official

Name: ANNE JONES
Title or Position: DIRECTOR OF OUTPATIENT SERVICES
Credential: M.S.
Phone: 414-871-6122