Provider Demographics
NPI:1114448511
Name:MCNEVIN, MOLLY A
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:A
Last Name:MCNEVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4254
Mailing Address - Country:US
Mailing Address - Phone:208-523-2490
Mailing Address - Fax:208-522-2603
Practice Address - Street 1:1301 MAIN ST STE 3B
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4452
Practice Address - Country:US
Practice Address - Phone:208-756-2927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker