Provider Demographics
NPI:1528160314
Name:DIVERSE CLINICAL SERVICES ASSOCIATES, INC.
Entity type:Organization
Organization Name:DIVERSE CLINICAL SERVICES ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BASILISA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRELLA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-347-7063
Mailing Address - Street 1:633 W WISCONSIN AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1918
Mailing Address - Country:US
Mailing Address - Phone:414-347-4063
Mailing Address - Fax:414-347-4075
Practice Address - Street 1:633 W WISCONSIN AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-1918
Practice Address - Country:US
Practice Address - Phone:414-347-4063
Practice Address - Fax:414-347-4075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2692-123103TC1900X
WI273180202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42206700Medicaid
WI39704500Medicaid
WI31786300Medicaid