Healthcare Provider Details

I. General information

NPI: 1548199243
Provider Name (Legal Business Name): SAGE NICOLE LEAX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 STONY BROOK RD
STONY BROOK NY
11790-2214
US

IV. Provider business mailing address

5 DORCHESTER DR
CORAM NY
11727-2310
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-0101
  • Fax: 631-444-0102
Mailing address:
  • Phone: 631-444-0101
  • Fax: 631-444-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: