Healthcare Provider Details

I. General information

NPI: 1861504813
Provider Name (Legal Business Name): PROFESSIONAL SERVICES GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 63RD ST
KENOSHA WI
53143-4454
US

IV. Provider business mailing address

6233 39TH AVE
KENOSHA WI
53142-7015
US

V. Phone/Fax

Practice location:
  • Phone: 262-652-2406
  • Fax: 262-652-2408
Mailing address:
  • Phone: 262-654-1004
  • Fax: 262-654-6960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JONATHAN GRAPENGIESER
Title or Position: CLINICAL DIRECTOR
Credential: PSYD
Phone: 262-654-1004