Healthcare Provider Details

I. General information

NPI: 1578757910
Provider Name (Legal Business Name): SAGE SOCIAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PEACEFUL LN
CONVERSE TX
78109-1007
US

IV. Provider business mailing address

101 PEACEFUL LN
CONVERSE TX
78109-1007
US

V. Phone/Fax

Practice location:
  • Phone: 210-725-3413
  • Fax: 210-945-8489
Mailing address:
  • Phone: 210-725-3413
  • Fax: 210-945-8489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20064
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. MELANIE MARIE HENNIS
Title or Position: LICENSED PROFESIONAL COUNSELOR
Credential: LPC
Phone: 210-725-3413