Basic Information
| Provider Information | |||||||||
| NPI: | 1568763324 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILESTONES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1620 N MAIN ST | ||||||||
| Address2: | SUTIE #1 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945964653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252866050 | ||||||||
| FaxNumber: | 9259376782 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 N MAIN ST | ||||||||
| Address2: | SUITE #1 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945964653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252866050 | ||||||||
| FaxNumber: | 9259376782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2010 | ||||||||
| LastUpdateDate: | 05/06/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VICKERS | ||||||||
| AuthorizedOfficialFirstName: | TRACIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9252866050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | N | Agencies | Early Intervention Provider Agency | 251S00000X | N | Agencies | Community/Behavioral Health | 103K00000X | 16680 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.