Healthcare Provider Details

I. General information

NPI: 1447854559
Provider Name (Legal Business Name): BROOKE ELIZABETH BARTHOLOMEW SAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9792 HIGHWAY 70
MINOCQUA WI
54548-8747
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 715-358-7377
  • Fax: 715-356-9379
Mailing address:
  • Phone: 715-387-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16433-131
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: