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General NPI Number Information
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NPI Number | 1003422726
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Entity Type | Organization
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Legal Business Name | WISCONSIN HEALTHCARE FAMILY PRACTICES AND BEHAVIORAL SERVICES LLC
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Dates
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Enumeration Date | 09/17/2020
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Last Update Date | 09/17/2020
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Provider Practice Location Address
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Address Line | 10721 W CAPITOL DR STE G103
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City | WAUWATOSA
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State | WI
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Zip | 53222-1210
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Country | US
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Telephone | 414-219-9420
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Fax | 414-909-8674
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Provider Business Mailing Address
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Address Line | 10721 W CAPITOL DR STE G103
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City | WAUWATOSA
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State | WI
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Zip | 53222-1210
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Country | US
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Telephone | 414-219-9420
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Fax | 414-909-8674
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Authorized Official
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Title or Position | FNP-BC, PMHNP-BC
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Name | KENYA ROBERTSON
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Credential |
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Telephone | 414-219-9420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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