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General NPI Number Information
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NPI Number | 1003315391
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Entity Type | Organization
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Legal Business Name | SAGE COMMUNITY COUNSELING LLC
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Dates
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Enumeration Date | 02/02/2018
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Last Update Date | 02/02/2018
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Provider Practice Location Address
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Address Line | 2239B TACKETTS MILL DR
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City | WOODBRIDGE
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State | VA
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Zip | 22192-3026
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Country | US
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Telephone | 703-508-3565
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Fax | 866-377-6092
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Provider Business Mailing Address
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Address Line | 478 HARBOR SIDE ST
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City | WOODBRIDGE
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State | VA
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Zip | 22191-5470
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Country | US
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Telephone | 703-508-3565
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Fax | 866-377-6092
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Authorized Official
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Title or Position | PRINCIPLE
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Name | MRS. PAULA JEAN FLYNN
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Credential | LCSW
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Telephone | 703-508-3565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904007725
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License Number State | VA
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