Healthcare Provider Details

I. General information

NPI: 1649818642
Provider Name (Legal Business Name): MALLORIE ELY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2019
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 HIGHWAY 2 STE D
SANDPOINT ID
83864-2713
US

IV. Provider business mailing address

PO BOX 484
KOOTENAI ID
83840-0484
US

V. Phone/Fax

Practice location:
  • Phone: 208-610-0996
  • Fax:
Mailing address:
  • Phone: 208-610-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MALLORIE ELY
Title or Position: OWNER/CLINICIAN
Credential: LCSW
Phone: 208-610-0996