Provider Demographics
NPI:1558762245
Name:SAGE ADDICTION TREATMENT SERVICES
Entity Type:Organization
Organization Name:SAGE ADDICTION TREATMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:CLINICAL PSYCHOLOGIS
Authorized Official - Phone:505-977-9180
Mailing Address - Street 1:2929 COORS BLVD NW STE 100D
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1272
Mailing Address - Country:US
Mailing Address - Phone:505-977-9180
Mailing Address - Fax:
Practice Address - Street 1:2929 COORS BLVD NW STE 100D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1272
Practice Address - Country:US
Practice Address - Phone:505-977-9180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0930103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1518952662Medicaid