Basic Information
| Provider Information | |||||||||
| NPI: | 1629365879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEISSEN | ||||||||
| FirstName: | SHAYE | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ONSTOT | ||||||||
| OtherFirstName: | SHAYE | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3205 N ACADEMY BLVD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2828 INTERNATIONAL CIR | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2011 | ||||||||
| LastUpdateDate: | 09/20/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LPC.0012830 | CO | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | 2011013737 | MO | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | LPC.0012830 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 31200052 | 05 | CO | MEDICAID |