1235760711 NPI number — ERIKA LYNN BROXTON

Table of content: ERIKA LYNN BROXTON (NPI 1235760711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235760711 NPI number — ERIKA LYNN BROXTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROXTON
Provider First Name:
ERIKA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235760711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4241 W HAWTHORNE TRACE RD APT 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53209-1033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-573-9322
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3026 W CONCORDIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53216-3853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-253-7494
Provider Business Practice Location Address Fax Number:
414-296-0273
Provider Enumeration Date:
02/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 132309-121 . This is a "SOCIAL WORK LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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