Healthcare Provider Details

I. General information

NPI: 1346079266
Provider Name (Legal Business Name): S.A.G.E. HOLISTIC INDIVIDUAL, MARRIAGE & FAMILY THERAPY PROFESSIONAL C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 N TUSTIN AVE
SANTA ANA CA
92705-7827
US

IV. Provider business mailing address

2050 N TUSTIN AVE
SANTA ANA CA
92705-7827
US

V. Phone/Fax

Practice location:
  • Phone: 714-391-3853
  • Fax: 888-338-1074
Mailing address:
  • Phone: 714-391-3853
  • Fax: 888-338-1074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. EMILY CELIS
Title or Position: CEO
Credential: MS, LMFT
Phone: 714-391-3853