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General NPI Number Information
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NPI Number | 1023427812
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Entity Type | Organization
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Legal Business Name | SAGE PHD
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Dates
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Enumeration Date | 08/06/2014
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Last Update Date | 08/06/2014
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Provider Practice Location Address
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Address Line | 2801 CAMINO DEL RIO S SUITE 200
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City | SAN DIEGO
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State | CA
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Zip | 92108-3800
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Country | US
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Telephone | 858-228-7701
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Fax | 619-269-9777
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Provider Business Mailing Address
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Address Line | 2801 CAMINO DEL RIO S SUITE 200
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City | SAN DIEGO
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State | CA
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Zip | 92108-3800
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Country | US
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Telephone | 858-228-7701
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Fax | 619-269-9777
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | SAGE SCHUITEVOERDER
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Credential | PHD
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Telephone | 858-228-7701
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 25395
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License Number State | CA
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