Healthcare Provider Details

I. General information

NPI: 1336106830
Provider Name (Legal Business Name): DIANNE LADON PHILLIPS-MILLER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: DIANNE LADON WIMBERLEY PH.D.

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 S WASHINGTON ST
MOSCOW ID
83843-3049
US

IV. Provider business mailing address

814 S WASHINGTON ST
MOSCOW ID
83843-3049
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-0619
  • Fax: 208-882-4774
Mailing address:
  • Phone: 208-882-0619
  • Fax: 208-882-4774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY 288
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: