Basic Information
| Provider Information | |||||||||
| NPI: | 1649582545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLSPAUGH | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MITSCHE | ||||||||
| OtherFirstName: | DIANA | ||||||||
| OtherMiddleName: | F | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15312 W BELOIT RD | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531517447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626415771 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 042668 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1649582545 | 05 | WI | MEDICAID |