MEDICARE: SAGEFORTH PSYCHOLOGICAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103G00000X	Clinical Neuropsychologist
2	103TB0200X	Cognitive & Behavioral Psychologist
3	103TC2200X	Clinical Child & Adolescent Psychologist
4	103T00000X	Psychologist

General Provider Information

NPI Number	:	1114683372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGEFORTH PSYCHOLOGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	552 FORT EVANS RD STE 206
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20176-3378
Country	:	US
Telephone Number	:	703-777-7755
Fax Number	:

Provider Business Practice Location Address
First Line	:	552 FORT EVANS RD STE 206
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20176-3378
Country	:	US
Telephone Number	:	703-777-7755
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DR. SARAH MAHNAZ VANLANDINGHAM
Credential	:	PSYD
Telephone Number	:	703-777-7755

Provider Enumeration Date	:	11/11/2021
Last Update Date	:	05/17/2022

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