Provider Demographics
NPI:1669004230
Name:MILLSPAUGH, JEFFERY TYLER (SLP)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:TYLER
Last Name:MILLSPAUGH
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N COVINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-6526
Mailing Address - Country:US
Mailing Address - Phone:316-215-4719
Mailing Address - Fax:
Practice Address - Street 1:1220 WW II MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156
Practice Address - Country:US
Practice Address - Phone:620-221-9479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4020235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist