Provider Demographics
NPI:1942470661
Name:KENOSHA HUMAN DEVELOPMENT SERVICES, INC
Entity Type:Organization
Organization Name:KENOSHA HUMAN DEVELOPMENT SERVICES, INC
Other - Org Name:KENOSHA YOUTH DEVELOPMENT SERVICES, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-764-8555
Mailing Address - Street 1:3536 52ND ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-2662
Mailing Address - Country:US
Mailing Address - Phone:262-842-0538
Mailing Address - Fax:262-842-0539
Practice Address - Street 1:3536 52ND ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-2662
Practice Address - Country:US
Practice Address - Phone:262-842-0538
Practice Address - Fax:262-842-0539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32975970Medicaid