Healthcare Provider Details

I. General information

NPI: 1942470661
Provider Name (Legal Business Name): KENOSHA HUMAN DEVELOPMENT SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 52ND ST
KENOSHA WI
53144-2662
US

IV. Provider business mailing address

3536 52ND ST
KENOSHA WI
53144-2662
US

V. Phone/Fax

Practice location:
  • Phone: 262-842-0538
  • Fax: 262-842-0539
Mailing address:
  • Phone: 262-842-0538
  • Fax: 262-842-0539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JEANNINE MARIE FIELD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 262-764-8555