Healthcare Provider Details

I. General information

NPI: 1811830003
Provider Name (Legal Business Name): MALLORY CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 05/19/2026
Certification Date: 04/20/2026
Deactivation Date: 04/20/2026
Reactivation Date: 05/19/2026

III. Provider practice location address

1220 7TH AVE E
TWIN FALLS ID
83301-6914
US

IV. Provider business mailing address

1220 7TH AVE E
TWIN FALLS ID
83301-6914
US

V. Phone/Fax

Practice location:
  • Phone: 208-680-0258
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: