Provider Demographics
NPI:1417108747
Name:WISCONSIN COMMUNITY SERVICES, INC.
Entity Type:Organization
Organization Name:WISCONSIN COMMUNITY SERVICES, INC.
Other - Org Name:UNLIMITED POTENTIAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-290-0499
Mailing Address - Street 1:3732 W WISCONSIN AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208
Mailing Address - Country:US
Mailing Address - Phone:414-290-0400
Mailing Address - Fax:414-271-4605
Practice Address - Street 1:3734 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208
Practice Address - Country:US
Practice Address - Phone:414-290-0440
Practice Address - Fax:414-226-0351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 261QM0801X
WI52D0914885291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No291U00000XLaboratoriesClinical Medical Laboratory