Provider Demographics
NPI:1871925834
Name:ELY, MALLORIE (LCSW)
Entity type:Individual
Prefix:
First Name:MALLORIE
Middle Name:
Last Name:ELY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:208-625-2046
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW35962104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker