MEDICARE: PROFESSIONAL CLINICAL SERVICES OF WI 1 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor
3	101YP2500X	Professional Counselor
4	102L00000X	Psychoanalyst
5	103T00000X	Psychologist
6	103TA0700X	Adult Development & Aging Psychologist
7	103TB0200X	Cognitive & Behavioral Psychologist
8	103TC1900X	Counseling Psychologist
9	103TH0100X	Health Service Psychologist
10	103TP0016X	Prescribing (Medical) Psychologist
11	103TP0814X	Psychoanalysis Psychologist
12	103TP2701X	Group Psychotherapy Psychologist
13	2084P0800X	Psychiatry Physician
14	2084P0805X	Geriatric Psychiatry Physician
15	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1508133158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL CLINICAL SERVICES OF WI 1 LLC

Provider Business Mailing Address
First Line	:	292 OLD DIXIE HWY
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32962-2947
Country	:	US
Telephone Number	:	772-494-2700
Fax Number	:	772-562-8127

Provider Business Practice Location Address
First Line	:	292 OLD DIXIE HWY
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32962-2947
Country	:	US
Telephone Number	:	772-494-2700
Fax Number	:	772-562-8127

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. DAVID EDWARD SOMMERFELD
Credential	:
Telephone Number	:	772-494-2700

Provider Enumeration Date	:	11/28/2011
Last Update Date	:	11/28/2011

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