Provider Demographics
NPI:1154200400
Name:MALLOY, MCKENNA
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:MALLOY
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 1:10602 N 37TH E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5498
Mailing Address - Country:US
Mailing Address - Phone:208-219-8336
Mailing Address - Fax:
Practice Address - Street 1:1820 E 17TH ST STE 330
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6400
Practice Address - Country:US
Practice Address - Phone:208-219-8336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-30
Last Update Date:2025-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist