Provider Demographics
NPI:1396821005
Name:PROFESSIONAL SERVICES GROUP, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL SERVICES GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-652-2406
Mailing Address - Street 1:6233 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7015
Mailing Address - Country:US
Mailing Address - Phone:262-654-1004
Mailing Address - Fax:262-654-6960
Practice Address - Street 1:1126 S 70TH ST
Practice Address - Street 2:SUITE S507
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3151
Practice Address - Country:US
Practice Address - Phone:414-727-2789
Practice Address - Fax:414-476-8695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WI2365101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42235000Medicaid
WI000084462Medicare ID - Type UnspecifiedMEDICARE