Provider Demographics
NPI:1750308649
Name:BROECKERT, ROBERT R (MS CCC-A)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:R
Last Name:BROECKERT
Suffix:
Gender:M
Credentials:MS CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S CLARA ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4061
Mailing Address - Country:US
Mailing Address - Phone:920-213-0767
Mailing Address - Fax:
Practice Address - Street 1:4650 W SPENCER ST
Practice Address - Street 2:SUITE 31
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-9106
Practice Address - Country:US
Practice Address - Phone:920-738-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI190-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41128800Medicaid
WI000081033Medicare PIN