Provider Demographics
NPI:1508133158
Name:PROFESSIONAL CLINICAL SERVICES OF WI 1 LLC
Entity Type:Organization
Organization Name:PROFESSIONAL CLINICAL SERVICES OF WI 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SOMMERFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-494-2700
Mailing Address - Street 1:292 OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-2947
Mailing Address - Country:US
Mailing Address - Phone:772-494-2700
Mailing Address - Fax:772-562-8127
Practice Address - Street 1:292 OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32962-2947
Practice Address - Country:US
Practice Address - Phone:772-494-2700
Practice Address - Fax:772-562-8127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty