Healthcare Provider Details

I. General information

NPI: 1275586323
Provider Name (Legal Business Name): RACINE PSYCHOLOGICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 LAKE AVE SUITE 101
RACINE WI
53403-1566
US

IV. Provider business mailing address

840 LAKE AVE SUITE 101
RACINE WI
53403-1566
US

V. Phone/Fax

Practice location:
  • Phone: 262-634-8688
  • Fax: 262-634-7547
Mailing address:
  • Phone: 262-634-8688
  • Fax: 262-634-7547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2220
License Number StateWI

VIII. Authorized Official

Name: MARY JANE WHITMORE
Title or Position: DIRECTOR
Credential: LCSW, CSAC
Phone: 262-634-8688