Healthcare Provider Details

I. General information

NPI: 1033967518
Provider Name (Legal Business Name): SAGE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3807 WRIGHTSVILLE AVE STE 24
WILMINGTON NC
28403-8463
US

IV. Provider business mailing address

4302 WRIGHTSVILLE AVE
WILMINGTON NC
28403-6336
US

V. Phone/Fax

Practice location:
  • Phone: 910-788-2375
  • Fax:
Mailing address:
  • Phone: 910-788-2375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLY COLWELL
Title or Position: BILLING/CREDENTIALING
Credential:
Phone: 910-524-8627