Provider Demographics
NPI:1588007652
Name:SAGAMORE SCHOOL, LLC
Entity Type:Organization
Organization Name:SAGAMORE SCHOOL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RACHEL
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, CCC-SLP
Authorized Official - Phone:954-420-9566
Mailing Address - Street 1:6820 LYONS TECHNOLOGY CIRCLE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073
Mailing Address - Country:US
Mailing Address - Phone:954-420-9566
Mailing Address - Fax:954-905-4382
Practice Address - Street 1:6820 LYONS TECHNOLOGY PKWY
Practice Address - Street 2:SUITE 230
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-4314
Practice Address - Country:US
Practice Address - Phone:954-420-9566
Practice Address - Fax:954-905-4382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW97481041C0700X
FLMT1955106H00000X
FLSA5302235Z00000X
FLSA7678235Z00000X
FLSA4869235Z00000X
FLSA10302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty