Provider Demographics
NPI:1114385952
Name:SAGE BEAR COUNSELING, LLC
Entity Type:Organization
Organization Name:SAGE BEAR COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:GENEVIEVE
Authorized Official - Last Name:DAVIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-830-6030
Mailing Address - Street 1:3150 CARLISLE BLVD NE
Mailing Address - Street 2:SUITE 22
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1678
Mailing Address - Country:US
Mailing Address - Phone:505-830-6030
Mailing Address - Fax:505-830-6031
Practice Address - Street 1:3150 CARLISLE BLVD NE
Practice Address - Street 2:SUITE 22
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1678
Practice Address - Country:US
Practice Address - Phone:505-830-6030
Practice Address - Fax:505-830-6031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-18531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM95656Medicaid