Provider Demographics
NPI:1578644415
Name:SAGE NEUROSCIENCE CENTER INC
Entity Type:Organization
Organization Name:SAGE NEUROSCIENCE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-884-1114
Mailing Address - Street 1:7850 JEFFERSON ST NE STE 300
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4314
Mailing Address - Country:US
Mailing Address - Phone:505-884-1114
Mailing Address - Fax:505-359-3010
Practice Address - Street 1:7850 JEFFERSON ST NE STE 300
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4314
Practice Address - Country:US
Practice Address - Phone:505-884-1114
Practice Address - Fax:505-359-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0751101YM0800X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1962463877OtherINDIVIDUAL NPI