Provider Demographics
NPI:1275586323
Name:RACINE PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:RACINE PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITMORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC
Authorized Official - Phone:262-634-8688
Mailing Address - Street 1:840 LAKE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1566
Mailing Address - Country:US
Mailing Address - Phone:262-634-8688
Mailing Address - Fax:262-634-7547
Practice Address - Street 1:840 LAKE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1566
Practice Address - Country:US
Practice Address - Phone:262-634-8688
Practice Address - Fax:262-634-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2220261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42216900Medicaid
WI42216900Medicaid