Healthcare Provider Details

I. General information

NPI: 1073314415
Provider Name (Legal Business Name): VIRGINIAS PLAYHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 N 19TH PL
MILWAUKEE WI
53209-6836
US

IV. Provider business mailing address

4316 N 19TH PL
MILWAUKEE WI
53209-6836
US

V. Phone/Fax

Practice location:
  • Phone: 414-388-4186
  • Fax: 414-388-4186
Mailing address:
  • Phone: 414-388-4186
  • Fax: 414-388-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: KENYETTA WILLIAMS
Title or Position: OWNER
Credential:
Phone: 414-388-4186