=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932612348
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGE WELLNESS, A MARRIAGE AND FAMILY THERAPY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2017
-----------------------------------------------------
Last Update Date | 08/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E SAN MARCOS BLVD STE 400
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92069-2988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-566-7738
-----------------------------------------------------
Fax | 760-919-3139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E SAN MARCOS BLVD STE 400
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92069-2988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-566-7738
-----------------------------------------------------
Fax | 760-919-3139
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MIRANDA BOWERSOX-MOREHEAD
-----------------------------------------------------
Credential | MFT
-----------------------------------------------------
Telephone | 760-566-7738
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------