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General NPI Number Information
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NPI Number | 1396821005
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL SERVICES GROUP, INC.
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Dates
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Enumeration Date | 10/27/2006
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Last Update Date | 06/30/2008
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Provider Practice Location Address
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Address Line | 1126 S 70TH ST SUITE S507
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City | WEST ALLIS
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State | WI
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Zip | 53214-3151
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Country | US
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Telephone | 414-727-2789
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Fax | 414-476-8695
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Provider Business Mailing Address
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Address Line | 6233 39TH AVE
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City | KENOSHA
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State | WI
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Zip | 53142-7015
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Country | US
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Telephone | 262-654-1004
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Fax | 262-654-6960
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. BRIAN A. WOLF
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Credential | PHD.
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Telephone | 262-652-2406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 2365
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License Number State | WI
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