Healthcare Provider Details

I. General information

NPI: 1093913709
Provider Name (Legal Business Name): BROADSTEP-WISCONSIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 05/19/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 S 24TH ST
MILWAUKEE WI
53215-4414
US

IV. Provider business mailing address

5551 N. 51ST BLVD.
MILWAUKEE WI
53128
US

V. Phone/Fax

Practice location:
  • Phone: 414-671-6965
  • Fax:
Mailing address:
  • Phone: 414-527-6970
  • Fax: 414-527-6971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number1006139
License Number StateWI

VIII. Authorized Official

Name: JULIANNE YOPPS
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 414-930-4421