Provider Demographics
NPI:1407455926
Name:WISENER, ELISHA (LMFT)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:WISENER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 LAVELETT LN
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-2214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7680 GODDARD ST STE 120
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-8233
Practice Address - Country:US
Practice Address - Phone:719-313-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFT.0001511106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist