Provider Demographics
NPI:1134327943
Name:BROADSTEP-WISCONSIN, INC.
Entity Type:Organization
Organization Name:BROADSTEP-WISCONSIN, INC.
Other - Org Name:MANITOBA GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JULIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOPPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-930-4421
Mailing Address - Street 1:3018 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3944
Mailing Address - Country:US
Mailing Address - Phone:414-483-0156
Mailing Address - Fax:414-747-4760
Practice Address - Street 1:3018 S 9TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3944
Practice Address - Country:US
Practice Address - Phone:414-483-0156
Practice Address - Fax:414-747-4760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1004077322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children