Provider Demographics
NPI:1154629483
Name:PSYCHOLOGICAL EVALUATION & CONSULTING SERVICES
Entity Type:Organization
Organization Name:PSYCHOLOGICAL EVALUATION & CONSULTING SERVICES
Other - Org Name:WCMHCC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KANE
Authorized Official - Suffix:III
Authorized Official - Credentials:MSED
Authorized Official - Phone:262-242-3810
Mailing Address - Street 1:10532 N PORT WASHINGTON RD
Mailing Address - Street 2:STE 1B
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5563
Mailing Address - Country:US
Mailing Address - Phone:262-242-3810
Mailing Address - Fax:
Practice Address - Street 1:1322 W TOWNE SQUARE RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5046
Practice Address - Country:US
Practice Address - Phone:262-242-3810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)