Healthcare Provider Details

I. General information

NPI: 1588605257
Provider Name (Legal Business Name): RICHARD H BROACH APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E NORTH ST
WAUKESHA WI
53188-3718
US

IV. Provider business mailing address

309 E NORTH ST
WAUKESHA WI
53188-3718
US

V. Phone/Fax

Practice location:
  • Phone: 414-672-1353
  • Fax: 414-385-7552
Mailing address:
  • Phone: 414-672-1353
  • Fax: 414-385-7552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3576125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number4270
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: