Healthcare Provider Details

I. General information

NPI: 1730899881
Provider Name (Legal Business Name): SAGE STOUT JOHANNESSEN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAGE AMBER STOUT DPT

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 BERKMAR DR STE A1
CHARLOTTESVILLE VA
22901-1593
US

IV. Provider business mailing address

1618 CAMBRIDGE CIR
CHARLOTTESVILLE VA
22903-1316
US

V. Phone/Fax

Practice location:
  • Phone: 434-979-8628
  • Fax:
Mailing address:
  • Phone: 802-922-0753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2305212499
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: