Basic Information
| Provider Information | |||||||||
| NPI: | 1629429782 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MENTAL WELLNESS CLINIC OF COEUR D ALENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1105 W IRONWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086761003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1105 W IRONWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086761003 | ||||||||
| FaxNumber: | 2086761009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2016 | ||||||||
| LastUpdateDate: | 06/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | LAGROU | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2086761003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.