=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881301471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGE WISDOM COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2022
-----------------------------------------------------
Last Update Date | 09/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3214 W HUTTON RD
-----------------------------------------------------
City | WOOSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44691-9040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-628-0176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 E LIBERTY ST STE 375
-----------------------------------------------------
City | WOOSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44691-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-800-5471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GENAYE LADOUSIER
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 209-628-0176
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------