Provider Demographics
NPI:1154514776
Name:SOCIAL REHABILITATION AND RESIDENTIAL RESOURCES, INC.
Entity type:Organization
Organization Name:SOCIAL REHABILITATION AND RESIDENTIAL RESOURCES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:KINCAID
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:414-546-6880
Mailing Address - Street 1:9330 W LINCOLN AVE STE 21
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2300
Mailing Address - Country:US
Mailing Address - Phone:414-546-6880
Mailing Address - Fax:414-546-6234
Practice Address - Street 1:9330 W LINCOLN AVE STE 21
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2300
Practice Address - Country:US
Practice Address - Phone:414-546-6880
Practice Address - Fax:414-546-6234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2611251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42242500Medicaid