Healthcare Provider Details

I. General information

NPI: 1497680938
Provider Name (Legal Business Name): ELLIS E MISCAVAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 N 124TH ST
BROOKFIELD WI
53005-2489
US

IV. Provider business mailing address

3505 N 124TH ST
BROOKFIELD WI
53005-2489
US

V. Phone/Fax

Practice location:
  • Phone: 414-431-4444
  • Fax:
Mailing address:
  • Phone: 414-431-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number9089-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: