Provider Demographics
NPI:1588605257
Name:BROACH, RICHARD H (APNP)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:H
Last Name:BROACH
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3718
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:414-385-7552
Practice Address - Street 1:309 E NORTH ST
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3718
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:414-385-7552
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3576125101YP2500X
WI4270364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40995000Medicaid
WI521805Medicare Oscar/Certification
WI521830Medicare Oscar/Certification
WI40995000Medicaid