Basic Information
Provider Information | |||||||||
NPI: | 1114565405 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEMILLE | ||||||||
FirstName: | DENNIS | ||||||||
MiddleName: | WADE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILLET | ||||||||
OtherFirstName: | DENNIS | ||||||||
OtherMiddleName: | WADE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: | JR. | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 107 S DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992021510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098384651 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 127 W BOONE AVE | ||||||||
Address2: |   | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992012309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098384651 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2019 | ||||||||
LastUpdateDate: | 03/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CG61221709 |   | N |   | Behavioral Health & Social Service Providers | Counselor |   | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 101YM0800X | MC61258642 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.