| Mallorie Ely, Llc | |
|
1009 Highway 2 Ste D Sandpoint ID 83864-2713 | |
| (208) 610-0996 | |
| Not Available |
| Full Name | Mallorie Ely, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 1009 Highway 2 Ste D, Sandpoint, Idaho |
| Authorized Official Name and Position | Mallorie Ely (OWNER/CLINICIAN) |
| Authorized Official Contact | 2086100996 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Mallorie Ely, Llc Po Box 484 Kootenai ID 83840-0484 Ph: (208) 610-0996 | Mallorie Ely, Llc 1009 Highway 2 Ste D Sandpoint ID 83864-2713 Ph: (208) 610-0996 |
| NPI Number | 1649818642 |
|---|---|
| Provider Enumeration Date | 12/20/2019 |
| Last Update Date | 08/08/2023 |
| Certification Date | 08/08/2023 |
| Medicare PECOS PAC ID | 6507293107 |
|---|---|
| Medicare Enrollment ID | O20200220001015 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1649818642 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Mallorie Ely |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1871925834 PECOS PAC ID: 1355637307 Enrollment ID: I20160831001214 |
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