MEDICARE: SAGE ADDICTION TREATMENT SERVICES

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist	0930	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558762245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGE ADDICTION TREATMENT SERVICES

Provider Business Mailing Address
First Line	:	2929 COORS BLVD NW STE 100D
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-1272
Country	:	US
Telephone Number	:	505-977-9180
Fax Number	:

Provider Business Practice Location Address
First Line	:	2929 COORS BLVD NW STE 100D
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-1272
Country	:	US
Telephone Number	:	505-977-9180
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/CLINICAL PSYCHOLOGIST
Name	:	DR. MARK S SIMPSON
Credential	:	CLINICAL PSYCHOLOGIS
Telephone Number	:	505-977-9180

Provider Enumeration Date	:	09/12/2014
Last Update Date	:	09/12/2014

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