MEDICARE: DR. SANDI LEA SAGE PH.D, LMHC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH5353	FL
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	MH5353	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z0439	OTHER	FL	BCBS FL

General Provider Information

NPI Number	:	1417144452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDI LEA SAGE PH.D, LMHC

Provider Business Mailing Address
First Line	:	10752 DEERWOOD PARK BLVD
Second Line	:	SUITE 100
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-4849
Country	:	US
Telephone Number	:	904-394-2903
Fax Number	:	904-394-2904

Provider Business Practice Location Address
First Line	:	10752 DEERWOOD PARK BLVD
Second Line	:	SUITE 100
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-4849
Country	:	US
Telephone Number	:	904-394-2903
Fax Number	:	904-394-2904

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2007
Last Update Date	:	03/16/2011

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