Healthcare Provider Details

I. General information

NPI: 1396814828
Provider Name (Legal Business Name): MILESTONE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 HIGHWAY AVE
HIGHLAND IN
46322-1631
US

IV. Provider business mailing address

2906 HIGHWAY AVE
HIGHLAND IN
46322-1631
US

V. Phone/Fax

Practice location:
  • Phone: 219-513-8311
  • Fax: 708-479-2112
Mailing address:
  • Phone: 219-513-8311
  • Fax: 708-479-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number17030805
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05006226A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number70012822
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateIN
# 9
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22004096A
License Number StateIN
# 10
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146009098
License Number StateIL

VIII. Authorized Official

Name: ANDREW T. HAVERSTOCK
Title or Position: MANAGER
Credential: PT
Phone: 219-229-0322