Healthcare Provider Details

I. General information

NPI: 1881242444
Provider Name (Legal Business Name): DENNIS MILLAGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 2ND ST W
CRESCO IA
52136-1334
US

IV. Provider business mailing address

504 2ND ST W
CRESCO IA
52136-1334
US

V. Phone/Fax

Practice location:
  • Phone: 563-379-8967
  • Fax:
Mailing address:
  • Phone: 563-379-8967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number096300
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number096300
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: