Provider Demographics
NPI:1235866120
Name:SAGE PSYCHOLOGICAL CONSULTING
Entity Type:Organization
Organization Name:SAGE PSYCHOLOGICAL CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRIPHINIA
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-317-2283
Mailing Address - Street 1:4062 PEACHTREE RD NE # 190A
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3021
Mailing Address - Country:US
Mailing Address - Phone:404-317-2283
Mailing Address - Fax:
Practice Address - Street 1:526 FOREST PKWY STE C
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-6140
Practice Address - Country:US
Practice Address - Phone:404-317-2283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003222721AMedicaid