=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811754997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGE & LORE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2024
-----------------------------------------------------
Last Update Date | 03/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1404 DEL PRADO BLVD S
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33990-3774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-310-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4085 HANCOCK BRIDGE PKWY STE 112-116
-----------------------------------------------------
City | NORTH FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33903-7219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | PETRA P WILKES
-----------------------------------------------------
Credential | MFT, MHC
-----------------------------------------------------
Telephone | 978-310-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------