Healthcare Provider Details

I. General information

NPI: 1467419200
Provider Name (Legal Business Name): FAMILY SERVICE OF RACINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 7TH STREET
RACINE WI
53403-1222
US

IV. Provider business mailing address

420 7TH STREET
RACINE WI
53403-1222
US

V. Phone/Fax

Practice location:
  • Phone: 262-634-2391
  • Fax: 262-634-5342
Mailing address:
  • Phone: 262-634-2391
  • Fax: 262-634-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1339
License Number StateWI

VIII. Authorized Official

Name: MR. KATIE L. OATSVALL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 262-634-2391