Healthcare Provider Details

I. General information

NPI: 1104649342
Provider Name (Legal Business Name): SAGE ALEXANDRA COLLIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAGE HAMMOND

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E RUDISILL BLVD STE 100B
FORT WAYNE IN
46806-1756
US

IV. Provider business mailing address

1550 E STATE ROAD 124
MONROE IN
46772-9658
US

V. Phone/Fax

Practice location:
  • Phone: 260-255-3665
  • Fax:
Mailing address:
  • Phone: 260-223-6877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: