Provider Demographics
NPI:1437744885
Name:MUCKELROY, MARY L (LMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:MUCKELROY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 MANGO DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5123
Mailing Address - Country:US
Mailing Address - Phone:972-822-0440
Mailing Address - Fax:
Practice Address - Street 1:2825 S MERIDIAN RD # 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7960
Practice Address - Country:US
Practice Address - Phone:208-297-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-40118101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health