Lara Patrice Gagne

Key facts

NPI

1124170550

Entity type

Individual (NPI type 1)

Primary specialty

Marriage & Family Therapist 106H00000X

License

REG. INTERN 48617 (CA)

Practice address

1044 Northwest Blvd Ste C
Coeur D Alene, ID 83814-2114

Phone

(208) 930-1740

Fax

(208) 930-1695

NPI assigned

Jan 17, 2007

Sex

Female

Sole proprietor

Yes

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Ambitions of Idaho, Inc Mental Health Clinic/Center (Including Community Mental Health Center) · Coeur D Alene, ID · NPI 1003145533
  Medicare reassignment NPD ID
• Ambitions of Idaho, Inc. Mental Health Clinic/Center (Including Community Mental Health Center) · Coeur D Alene, ID · NPI 1689133050
  NPD

Medicare participation

Medicare fee-for-service enrollment

Enrolled in ID

Eligible to order & refer

Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No

Medicare enrollment records

National Provider Directory

Medicare enrollment (NPD)

Yes

State licenses

Practice roles

Locations

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jan 9, 2024.

{
    "created_epoch": "1168992000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1704758400000",
    "number": "1124170550",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 544",
            "city": "CLAYTON",
            "state": "CA",
            "postal_code": "945170544",
            "telephone_number": "925-603-0186"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1044 NORTHWEST BLVD STE C",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "838142114",
            "telephone_number": "208-930-1740",
            "fax_number": "208-930-1695"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1410 Danzig Plz Ste 250",
            "address_purpose": "LOCATION",
            "city": "Concord",
            "state": "CA",
            "postal_code": "945207979",
            "country_code": "US",
            "telephone_number": "925-603-0186",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "GAGNE",
        "first_name": "LARA",
        "middle_name": "PATRICE",
        "name_prefix": "Miss",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-01-17",
        "last_updated": "2024-01-09",
        "certification_date": "2024-01-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "106H00000X",
            "taxonomy_group": "",
            "desc": "Marriage & Family Therapist",
            "state": "CA",
            "license": "REG. INTERN 48617",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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All providers in Coeur D Alene, ID · Marriage & Family Therapist in Idaho