Provider Demographics
NPI:1043077092
Name:SAGE SPACE RETREAT LLC
Entity Type:Organization
Organization Name:SAGE SPACE RETREAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGOUSES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:970-471-2297
Mailing Address - Street 1:8536 FOXHAVEN DR.
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-8698
Mailing Address - Country:US
Mailing Address - Phone:970-471-2297
Mailing Address - Fax:970-476-5299
Practice Address - Street 1:8536 FOXHAVEN DR.
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-8698
Practice Address - Country:US
Practice Address - Phone:720-963-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty