Provider Demographics
| NPI: | 1780828558 |
|---|---|
| Name: | MILESTONE PEDIATRICS LLC |
| Entity type: | Organization |
| Organization Name: | MILESTONE PEDIATRICS LLC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | DIRECTOR OF OPERATIONS & HUMAN RESO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | NICHELLE |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | DEAN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 480-855-0474 |
| Mailing Address - Street 1: | 1830 S ALMA SCHOOL RD |
| Mailing Address - Street 2: | SUITE 122 |
| Mailing Address - City: | MESA |
| Mailing Address - State: | AZ |
| Mailing Address - Zip Code: | 85210 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 480-855-0474 |
| Mailing Address - Fax: | 480-907-6855 |
| Practice Address - Street 1: | 1830 S ALMA SCHOOL RD |
| Practice Address - Street 2: | SUITE 122 |
| Practice Address - City: | MESA |
| Practice Address - State: | AZ |
| Practice Address - Zip Code: | 85210 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 480-855-0474 |
| Practice Address - Fax: | 480-907-6855 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2009-04-23 |
| Last Update Date: | 2023-05-18 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
| No | 224Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Group - Multi-Specialty | |
| No | 224ZR0403X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Driving and Community Mobility | Group - Multi-Specialty |
| No | 225A00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Music Therapist | Group - Multi-Specialty | |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 225XP0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | Group - Multi-Specialty |
| No | 225XR0403X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Driving and Community Mobility | Group - Multi-Specialty |
| No | 2355S0801X | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| AZ | 494003 | Medicaid |
