Provider Demographics
NPI:1619195344
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:OWNER PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAGROU
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:208-676-1003
Mailing Address - Street 1:500 N GOVERNMENT WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2913
Mailing Address - Country:US
Mailing Address - Phone:208-676-1003
Mailing Address - Fax:208-676-1009
Practice Address - Street 1:500 N GOVERNMENT WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2913
Practice Address - Country:US
Practice Address - Phone:208-676-1003
Practice Address - Fax:208-676-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty