Provider Demographics
NPI:1336106830
Name:PHILLIPS-MILLER, DIANNE LADON (PHD)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:LADON
Last Name:PHILLIPS-MILLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DIANNE
Other - Middle Name:LADON
Other - Last Name:WIMBERLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:814 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3049
Mailing Address - Country:US
Mailing Address - Phone:208-882-0619
Mailing Address - Fax:208-882-4774
Practice Address - Street 1:814 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3049
Practice Address - Country:US
Practice Address - Phone:208-882-0619
Practice Address - Fax:208-882-4774
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY 288103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP9205OtherAPS HEALTHCARE
IDN4460OtherBLUE CROSS OF IDAHO
IDCBH2228116OtherCIGNA