Basic Information
| Provider Information | |||||||||
| NPI: | 1306569041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAGE CHILD AND ADOLESCENT SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7850 JEFFERSON ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058841114 | ||||||||
| FaxNumber: | 5058843004 | ||||||||
| Practice Location | |||||||||
| Address1: | 7850 JEFFERSON ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058841114 | ||||||||
| FaxNumber: | 5058843004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2022 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | SUTTER | ||||||||
| AuthorizedOfficialFirstName: | REUBEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5058841114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAGE NEUROSCIENCE CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 2084P0804X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.