Healthcare Provider Details

I. General information

NPI: 1710586193
Provider Name (Legal Business Name): MR. SAGE GABRIEL ROGERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2020
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 E 8TH ST
PORT ANGELES WA
98362-6129
US

IV. Provider business mailing address

118 E 8TH ST
PORT ANGELES WA
98362-6129
US

V. Phone/Fax

Practice location:
  • Phone: 360-457-0431
  • Fax: 360-457-0493
Mailing address:
  • Phone: 360-457-0431
  • Fax: 360-457-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: