MEDICARE: TALISHA DAWN MILLAR BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		ID

General Provider Information

NPI Number	:	1083588040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TALISHA DAWN MILLAR BA

Provider Business Mailing Address
First Line	:	1820 E 17TH ST STE 355
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6453
Country	:	US
Telephone Number	:	208-497-0685
Fax Number	:

Provider Business Practice Location Address
First Line	:	1820 E 17TH ST STE 355
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6453
Country	:	US
Telephone Number	:	208-497-0685
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2025
Last Update Date	:	10/24/2025

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