=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437548039
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILESTONES PEDIATRIC THERAPY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2015
-----------------------------------------------------
Last Update Date | 01/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 802 KNOTTINGHAM DR
-----------------------------------------------------
City | OTTAWA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61350-4224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-712-8915
-----------------------------------------------------
Fax | 815-324-9107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 802 KNOTTINGHAM DR
-----------------------------------------------------
City | OTTAWA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61350-4224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-712-8915
-----------------------------------------------------
Fax | 815-324-9107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | KATIE ELISSA TARR
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 815-712-8915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 070016644
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 070016644
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------