Provider Demographics
NPI:1942352083
Name:DAMARIS MILTENBERGER LANGUAGE & LEARNING CENTER, LTD
Entity Type:Organization
Organization Name:DAMARIS MILTENBERGER LANGUAGE & LEARNING CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAMARIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MILTENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-351-1279
Mailing Address - Street 1:PO BOX 3295
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3295
Mailing Address - Country:US
Mailing Address - Phone:618-351-1279
Mailing Address - Fax:618-351-6369
Practice Address - Street 1:301 S. WALL ST.
Practice Address - Street 2:SUITE B
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902
Practice Address - Country:US
Practice Address - Phone:618-351-1279
Practice Address - Fax:618-351-6369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146002025235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL405587167001Medicaid