Healthcare Provider Details

I. General information

NPI: 1477121291
Provider Name (Legal Business Name): BROADSTEP-WISCONSIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/17/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 STONERIDGE DR
WATERTOWN WI
53098-3419
US

IV. Provider business mailing address

1205 S 70TH ST STE 202
WEST ALLIS WI
53214-3167
US

V. Phone/Fax

Practice location:
  • Phone: 920-390-2900
  • Fax: 920-390-2951
Mailing address:
  • Phone: 414-930-4421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

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