Provider Demographics
NPI:1013974849
Name:KENOSHA ACHIEVEMENT CENTER
Entity Type:Organization
Organization Name:KENOSHA ACHIEVEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEYKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-658-9650
Mailing Address - Street 1:1218 79TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6111
Mailing Address - Country:US
Mailing Address - Phone:262-658-9500
Mailing Address - Fax:262-658-9621
Practice Address - Street 1:1218 79TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6111
Practice Address - Country:US
Practice Address - Phone:262-658-9500
Practice Address - Fax:262-658-9621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41217500Medicaid