Healthcare Provider Details

I. General information

NPI: 1275866246
Provider Name (Legal Business Name): TATUM MARIE MILLER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11000 BALDY MOUNTAIN RD
SANDPOINT ID
83864-7250
US

IV. Provider business mailing address

PO BOX 571
BROOKINGS OR
97415-0049
US

V. Phone/Fax

Practice location:
  • Phone: 208-304-4123
  • Fax:
Mailing address:
  • Phone: 208-304-4123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-3942
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC8957
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: