# MENTAL WELLNESS CLINIC OF COEUR D ALENE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1376763474
- **Authorized official:** MRS. KELLY LAGROU BA (OWNER PROGRAM MANAGER)
- **Authorized official phone:** (208) 676-1003

## Contact information

- **Practice address:** 500 N GOVERNMENT WAY, SUITE 100, COEUR D ALENE, ID 83814-2913
- **Practice address phone:** (208) 676-1003
- **Practice address fax:** (208) 676-1009
- **Mailing address:** 500 N GOVERNMENT WAY, SUITE 100, COEUR D ALENE, ID 83814-2913
- **Mailing address phone:** (208) 676-1003
- **Mailing address fax:** (208) 676-1009

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | — | NULL | Yes |
| 174400000X | Specialist | — | — | Yes |

## Other

- **Enumeration date:** 04/30/2007
- **Last updated:** 08/22/2020