Healthcare Provider Details

I. General information

NPI: 1568535474
Provider Name (Legal Business Name): BROOKDALE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20700 WATERTOWN RD STE 206
WAUKESHA WI
53186
US

IV. Provider business mailing address

2717 N GRANDVIEW BLVD STE 202
WAUKESHA WI
53188
US

V. Phone/Fax

Practice location:
  • Phone: 262-513-0700
  • Fax: 262-513-0707
Mailing address:
  • Phone: 262-513-0700
  • Fax: 262-513-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number904 057
License Number StateWI

VIII. Authorized Official

Name: ILANA HADAR
Title or Position: OWNER
Credential: PHD
Phone: 262-717-0077