Provider Demographics
NPI:1649818642
Name:MALLORIE ELY, LLC
Entity type:Organization
Organization Name:MALLORIE ELY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MALLORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-610-0996
Mailing Address - Street 1:PO BOX 484
Mailing Address - Street 2:
Mailing Address - City:KOOTENAI
Mailing Address - State:ID
Mailing Address - Zip Code:83840-0484
Mailing Address - Country:US
Mailing Address - Phone:208-610-0996
Mailing Address - Fax:
Practice Address - Street 1:1009 HIGHWAY 2 STE D
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-2713
Practice Address - Country:US
Practice Address - Phone:208-610-0996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-20
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)