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General NPI Number Information
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NPI Number | 1861504813
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL SERVICES GROUP
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 06/13/2025
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Provider Practice Location Address
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Address Line | 2108 63RD ST
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City | KENOSHA
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State | WI
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Zip | 53143-4454
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Country | US
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Telephone | 262-652-2406
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Fax | 262-652-2408
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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 | JONATHAN GRAPENGIESER
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Credential | PSYD
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Telephone | 262-654-1004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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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 | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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