Provider Demographics
NPI:1861504813
Name:PROFESSIONAL SERVICES GROUP
Entity Type:Organization
Organization Name:PROFESSIONAL SERVICES GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAPENGIESER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:262-654-1004
Mailing Address - Street 1:6233 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7015
Mailing Address - Country:US
Mailing Address - Phone:262-654-1004
Mailing Address - Fax:262-654-6960
Practice Address - Street 1:2108 63RD ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4454
Practice Address - Country:US
Practice Address - Phone:262-652-2406
Practice Address - Fax:262-652-2408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
WI1749101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42125700Medicaid
WI42125700Medicaid