Provider Demographics
NPI:1659892479
Name:WISE, MEGAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:BRANCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 CANDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2627
Mailing Address - Country:US
Mailing Address - Phone:530-643-0033
Mailing Address - Fax:
Practice Address - Street 1:2600 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2669
Practice Address - Country:US
Practice Address - Phone:503-421-2679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-01
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3085103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic