Provider Demographics
NPI:1386981512
Name:WISECUP, MEAGEN
Entity type:Individual
Prefix:
First Name:MEAGEN
Middle Name:
Last Name:WISECUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 HORIZON DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:480 EAST AGATE AVE
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CO
Practice Address - Zip Code:80446
Practice Address - Country:US
Practice Address - Phone:970-887-2179
Practice Address - Fax:970-887-9311
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health