Healthcare Provider Details

I. General information

NPI: 1528160314
Provider Name (Legal Business Name): DIVERSE CLINICAL SERVICES ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 W WISCONSIN AVE SUITE 330
MILWAUKEE WI
53203-1918
US

IV. Provider business mailing address

633 W WISCONSIN AVE SUITE 330
MILWAUKEE WI
53203-1918
US

V. Phone/Fax

Practice location:
  • Phone: 414-347-4063
  • Fax: 414-347-4075
Mailing address:
  • Phone: 414-347-4063
  • Fax: 414-347-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2692-123
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number27318020
License Number StateWI

VIII. Authorized Official

Name: BASILISA VIRELLA
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 414-347-7063