Provider Demographics
NPI:1396814828
Name:MILESTONE THERAPY
Entity Type:Organization
Organization Name:MILESTONE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:T
Authorized Official - Last Name:HAVERSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:219-229-0322
Mailing Address - Street 1:2906 HIGHWAY AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1631
Mailing Address - Country:US
Mailing Address - Phone:219-513-8311
Mailing Address - Fax:708-479-2112
Practice Address - Street 1:2906 HIGHWAY AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1631
Practice Address - Country:US
Practice Address - Phone:219-513-8311
Practice Address - Fax:708-479-2112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17030805103K00000X
IN05006226A225100000X
IL70012822225100000X
2251P0200X
IL2251P0200X, 225XP0200X
IN2251P0200X, 225XP0200X
IN22004096A235Z00000X
IL146009098235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201283100AMedicaid