Healthcare Provider Details

I. General information

NPI: 1861165516
Provider Name (Legal Business Name): MACIE BROGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 S TAYLOR DR
SHEBOYGAN WI
53081-4766
US

IV. Provider business mailing address

W3272 STARDUST LN
SHEBOYGAN FALLS WI
53085-2417
US

V. Phone/Fax

Practice location:
  • Phone: 920-710-6867
  • Fax:
Mailing address:
  • Phone: 920-645-7606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: