Healthcare Provider Details

I. General information

NPI: 1386343820
Provider Name (Legal Business Name): STOTTS MEDICAL AND MENTAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 W FOND DU LAC AVE
MILWAUKEE WI
53216-1222
US

IV. Provider business mailing address

5600 W FOND DU LAC AVE
MILWAUKEE WI
53216-1222
US

V. Phone/Fax

Practice location:
  • Phone: 414-509-6084
  • Fax: 414-509-6885
Mailing address:
  • Phone: 414-509-6084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHARON DENISE J HILL
Title or Position: VICE PRESIDENT
Credential:
Phone: 414-509-6084