Provider Demographics
NPI:1467419200
Name:FAMILY SERVICE OF RACINE
Entity Type:Organization
Organization Name:FAMILY SERVICE OF RACINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:OATSVALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-634-2391
Mailing Address - Street 1:420 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1222
Mailing Address - Country:US
Mailing Address - Phone:262-634-2391
Mailing Address - Fax:262-634-5342
Practice Address - Street 1:420 7TH STREET
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1222
Practice Address - Country:US
Practice Address - Phone:262-634-2391
Practice Address - Fax:262-634-5342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1339101YM0800X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42128100Medicaid
WI42128100Medicaid