Healthcare Provider Details

I. General information

NPI: 1629579149
Provider Name (Legal Business Name): BCS OF WISCONSIN S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 N GRANDVIEW BLVD STE 102
WAUKESHA WI
53188-1672
US

IV. Provider business mailing address

39465 W 14 MILE RD
NOVI MI
48377-1600
US

V. Phone/Fax

Practice location:
  • Phone: 262-513-0700
  • Fax: 262-513-0707
Mailing address:
  • Phone: 248-859-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT ARTHUR CLEMENTE
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 248-859-3900