Healthcare Provider Details

I. General information

NPI: 1851889901
Provider Name (Legal Business Name): ELLIOT L BROCH PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 N 113TH ST STE 200
WAUWATOSA WI
53226-3209
US

IV. Provider business mailing address

3384 N 51ST BLVD
MILWAUKEE WI
53216-3238
US

V. Phone/Fax

Practice location:
  • Phone: 262-432-6600
  • Fax: 262-432-6604
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number906-58
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5283-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: