Provider Demographics
NPI:1083588040
Name:MILLAR, TALISHA DAWN (BA)
Entity type:Individual
Prefix:
First Name:TALISHA
Middle Name:DAWN
Last Name:MILLAR
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:TALISHA
Other - Middle Name:DAWN
Other - Last Name:CORGATELLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA
Mailing Address - Street 1:1820 E 17TH ST STE 355
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6453
Mailing Address - Country:US
Mailing Address - Phone:208-497-0685
Mailing Address - Fax:
Practice Address - Street 1:1820 E 17TH ST STE 355
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6453
Practice Address - Country:US
Practice Address - Phone:208-497-0685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician