Provider Demographics
NPI:1225440589
Name:SAGE, KIMBERLY (PSY D INTERN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SAGE
Suffix:
Gender:F
Credentials:PSY D INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 VISTA LN
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1902
Mailing Address - Country:US
Mailing Address - Phone:949-500-0566
Mailing Address - Fax:
Practice Address - Street 1:698 VISTA LN
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-1902
Practice Address - Country:US
Practice Address - Phone:949-500-0566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling