Provider Demographics
NPI:1598116659
Name:MENTAL WELLNESS CLINIC OF COEUR D ALENE
Entity Type:Organization
Organization Name:MENTAL WELLNESS CLINIC OF COEUR D ALENE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:MEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-964-9258
Mailing Address - Street 1:1105 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2613
Mailing Address - Country:US
Mailing Address - Phone:208-964-9258
Mailing Address - Fax:208-676-1009
Practice Address - Street 1:1105 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2613
Practice Address - Country:US
Practice Address - Phone:208-964-9258
Practice Address - Fax:208-676-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID000377Medicaid