Healthcare Provider Details

I. General information

NPI: 1619195344
Provider Name (Legal Business Name): MENTAL WELLNESS CLINIC OF COEUR D ALENE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N GOVERNMENT WAY SUITE 100
COEUR D ALENE ID
83814-2913
US

IV. Provider business mailing address

500 N GOVERNMENT WAY SUITE 100
COEUR D ALENE ID
83814-2913
US

V. Phone/Fax

Practice location:
  • Phone: 208-676-1003
  • Fax: 208-676-1009
Mailing address:
  • Phone: 208-676-1003
  • Fax: 208-676-1009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: KELLY P LAGROU
Title or Position: OWNER PROGRAM MANAGER
Credential: BA
Phone: 208-676-1003