1598213183 NPI number — MISTALA MILLER LMSW

Table of content: MISTALA MILLER LMSW (NPI 1598213183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598213183 NPI number — MISTALA MILLER LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
MISTALA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598213183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1387
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835-1387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-415-0299
Provider Business Mailing Address Fax Number:
208-625-2070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 S 13TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-245-4363
Provider Business Practice Location Address Fax Number:
208-245-4349
Provider Enumeration Date:
09/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  LMSW36012 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW-38874 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2122473 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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