Healthcare Provider Details

I. General information

NPI: 1235905985
Provider Name (Legal Business Name): AVERY MICHAEL SAGE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CORPORATE DR STE 486
SHELTON CT
06484-6266
US

IV. Provider business mailing address

1177 HIGH RIDGE RD STE 137
STAMFORD CT
06905-1221
US

V. Phone/Fax

Practice location:
  • Phone: 475-477-0278
  • Fax:
Mailing address:
  • Phone: 475-477-0278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number017432
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: