Healthcare Provider Details

I. General information

NPI: 1578184230
Provider Name (Legal Business Name): CIRQUE MEADOW PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CIRQUE MEADOW PSYCHIATRY 211 WEST MYRTE STREET, SUITE 207
FORT COLLINS CO
80521-2971
US

IV. Provider business mailing address

415 S WASHINGTON AVE
FORT COLLINS CO
80521-2571
US

V. Phone/Fax

Practice location:
  • Phone: 360-621-1409
  • Fax: 848-213-0217
Mailing address:
  • Phone: 360-621-1409
  • Fax: 848-213-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: VIRGINIA MACK
Title or Position: OWNER
Credential: APRN
Phone: 360-621-1409