Healthcare Provider Details

I. General information

NPI: 1073434957
Provider Name (Legal Business Name): SAMUEL MINER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16201 E INDIANA AVE STE 3400
SPOKANE VALLEY WA
99216-2830
US

IV. Provider business mailing address

1905 W APPLEWAY AVE
COEUR D ALENE ID
83814-8091
US

V. Phone/Fax

Practice location:
  • Phone: 509-900-3669
  • Fax:
Mailing address:
  • Phone: 530-537-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCBT.CB.70162972
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: