Provider Demographics
NPI:1225753072
Name:MOMO KANA, SAGE VIRGINA (MD)
Entity Type:Individual
Prefix:
First Name:SAGE VIRGINA
Middle Name:
Last Name:MOMO KANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19242 WHEATFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-1747
Mailing Address - Country:US
Mailing Address - Phone:240-883-0029
Mailing Address - Fax:
Practice Address - Street 1:19242 WHEATFIELD DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-1747
Practice Address - Country:US
Practice Address - Phone:240-883-0029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician