Basic Information
| Provider Information | |||||||||
| NPI: | 1376763474 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL WELLNESS CLINIC OF COEUR D ALENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 N GOVERNMENT WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086761003 | ||||||||
| FaxNumber: | 2086761009 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N GOVERNMENT WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086761003 | ||||||||
| FaxNumber: | 2086761009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAGROU | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2086761003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | BA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.