Provider Demographics
NPI:1336514165
Name:SAGESSE, MYLOUSE MILLIE
Entity Type:Individual
Prefix:
First Name:MYLOUSE
Middle Name:MILLIE
Last Name:SAGESSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MILOUSE
Other - Middle Name:
Other - Last Name:SAGESSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:4720 SALISBURY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6101
Mailing Address - Country:US
Mailing Address - Phone:904-562-1391
Mailing Address - Fax:904-562-1361
Practice Address - Street 1:4720 SALISBURY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6101
Practice Address - Country:US
Practice Address - Phone:904-562-1391
Practice Address - Fax:904-562-1361
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLMHC MH14311101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health