Provider Demographics
NPI:1417983917
Name:PSYCHOLOGICAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEINEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-646-6280
Mailing Address - Street 1:PO BOX 180680
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-0680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19435 W CAPITOL DRIVE
Practice Address - Street 2:SUITE L03
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2738
Practice Address - Country:US
Practice Address - Phone:262-646-6280
Practice Address - Fax:262-646-6284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2333-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000044840Medicare PIN