Provider Demographics
NPI:1649210360
Name:BROLL, LORRAINE T (PHD)
Entity Type:Individual
Prefix:DR
First Name:LORRAINE
Middle Name:T
Last Name:BROLL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7633 GANSER WAY
Mailing Address - Street 2:STE 204
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-2092
Mailing Address - Country:US
Mailing Address - Phone:608-829-1800
Mailing Address - Fax:608-829-1885
Practice Address - Street 1:7633 GANSER WAY
Practice Address - Street 2:STE 204
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2092
Practice Address - Country:US
Practice Address - Phone:608-829-1800
Practice Address - Fax:608-829-1885
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1106057103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39048000Medicaid
WI39048000Medicaid