Provider Demographics
NPI:1235703257
Name:SPROUTED SAGE LLC
Entity Type:Organization
Organization Name:SPROUTED SAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZI
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGUIB
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:734-222-9277
Mailing Address - Street 1:300 N 5TH AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-1447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 N 5TH AVE STE 210
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-1447
Practice Address - Country:US
Practice Address - Phone:734-222-9277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12311188OtherCAQH ID