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General NPI Number Information
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NPI Number | 1184841660
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Entity Type | Organization
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Legal Business Name | BROTOLOC INC. OUTPATIENT CLINIC
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 209 S TAFT ST
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City | WHITEWATER
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State | WI
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Zip | 53190-2139
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Country | US
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Telephone | 262-473-0480
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Fax | 262-473-0486
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Provider Business Mailing Address
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Address Line | 209 S TAFT ST
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City | WHITEWATER
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State | WI
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Zip | 53190-2139
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Country | US
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Telephone | 262-473-0480
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Fax | 262-473-0486
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | GARY S JOHNSON
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Credential |
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Telephone | 262-473-0480
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1115
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License Number State | WI
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