Healthcare Provider Details

I. General information

NPI: 1841514916
Provider Name (Legal Business Name): BELL THERAPY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
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: 262-652-1411
Mailing address:
  • Phone: 262-564-0067
  • Fax: 262-652-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1102
License Number StateWI

VIII. Authorized Official

Name: RONALD MENDYKE
Title or Position: CLINICAL DIRECTOR
Credential: MSW, LCSW
Phone: 414-527-6940