Basic Information
| Provider Information | |||||||||
| NPI: | 1396814828 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILESTONE THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2906 HIGHWAY AVE | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463221631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2195138311 | ||||||||
| FaxNumber: | 7084792112 | ||||||||
| Practice Location | |||||||||
| Address1: | 2906 HIGHWAY AVE | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463221631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2195138311 | ||||||||
| FaxNumber: | 7084792112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 04/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | HAVERSTOCK | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2192290322 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05006226A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | 22004096A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | 70012822 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | 146009098 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225XP0200X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225XP0200X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 2251P0200X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 2251P0200X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 103K00000X | 17030805 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 2251P0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 201283100A | 05 | IN | MEDICAID |