Healthcare Provider Details

I. General information

NPI: 1104974385
Provider Name (Legal Business Name): SAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3856 WONDERLAND HILL AVE
BOULDER CO
80304-1036
US

IV. Provider business mailing address

3856 WONDERLAND HILL AVE
BOULDER CO
80304-1036
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-3920
  • Fax:
Mailing address:
  • Phone: 303-443-3920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1350-00
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MICHELE ADRIENNE PACKARD
Title or Position: CEO
Credential: PHD
Phone: 303-443-3920