Healthcare Provider Details

I. General information

NPI: 1598098261
Provider Name (Legal Business Name): AMY SAGE RUPP LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 HERMOSA DR SE
ALBUQUERQUE NM
87108-4312
US

IV. Provider business mailing address

1025 HERMOSA DR SE
ALBUQUERQUE NM
87108-4312
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-7711
  • Fax: 505-268-5046
Mailing address:
  • Phone: 505-266-7711
  • Fax: 505-268-5046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0122421
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: