Provider Demographics
NPI:1417605197
Name:PSYCH AFFILIATES INC
Entity Type:Organization
Organization Name:PSYCH AFFILIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KOCHANIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-502-7216
Mailing Address - Street 1:11431 N PORT WASHINGTON RD STE 101B
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3463
Mailing Address - Country:US
Mailing Address - Phone:267-699-8834
Mailing Address - Fax:
Practice Address - Street 1:11431 N PORT WASHINGTON RD STE 101B
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3463
Practice Address - Country:US
Practice Address - Phone:414-502-7216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-12
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100190462Medicaid