Healthcare Provider Details

I. General information

NPI: 1376471797
Provider Name (Legal Business Name): BROOKE MORGAN MALLOY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 W PARK PL STE 303
COEUR D ALENE ID
83814-2784
US

IV. Provider business mailing address

2684 W LUMBER LN
COEUR D ALENE ID
83814-7419
US

V. Phone/Fax

Practice location:
  • Phone: 208-261-2255
  • Fax: 208-473-7271
Mailing address:
  • Phone: 607-761-3443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8971299
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC61321313
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: