MEDICARE: PROFESSIONAL SERVICES GROUP, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568548170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL SERVICES GROUP, INC.

Provider Business Mailing Address
First Line	:	6233 39TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-7015
Country	:	US
Telephone Number	:	262-654-1004
Fax Number	:	262-654-6960

Provider Business Practice Location Address
First Line	:	2323 N 25TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-1003
Country	:	US
Telephone Number	:	414-344-3061
Fax Number	:	414-344-1060

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DR. BRIAN A. WOLF
Credential	:	PHD
Telephone Number	:	262-652-2406

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	06/30/2008

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