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General NPI Number Information
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NPI Number | 1649645557
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Entity Type | Organization
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Legal Business Name | SAGE BEHAVIORAL HEALTH LLC
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Dates
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Enumeration Date | 12/02/2015
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Last Update Date | 11/17/2016
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Provider Practice Location Address
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Address Line | RR 1 BOX 184-9
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City | S COFFEYVILLE
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State | OK
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Zip | 74072-9784
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Country | US
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Telephone | 918-809-7919
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Fax |
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Provider Business Mailing Address
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Address Line | RR 1 BOX 184-9
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City | S COFFEYVILLE
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State | OK
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Zip | 74072-9784
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Country | US
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Telephone | 918-809-7919
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MRS. JACKIE SCOTT
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Credential | M.A, LPC, LCPC
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Telephone | 918-809-7919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 5538
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License Number State | OK
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