Healthcare Provider Details

I. General information

NPI: 1578845962
Provider Name (Legal Business Name): BLUE SAGE COUNSELING AND PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 BETTS ST NE
ALBUQUERQUE NM
87112-3103
US

IV. Provider business mailing address

1839 BETTS ST NE
ALBUQUERQUE NM
87112-3103
US

V. Phone/Fax

Practice location:
  • Phone: 505-463-1829
  • Fax:
Mailing address:
  • Phone: 505-463-1829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05493
License Number StateNM

VIII. Authorized Official

Name: MR. RUSSELL E. ADAMS
Title or Position: PRESIDENT
Credential: LISW
Phone: 505-463-1829