Provider Demographics
NPI:1629523261
Name:SAGE, BROOKE ANN
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANN
Last Name:SAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2917
Mailing Address - Country:US
Mailing Address - Phone:231-723-7743
Mailing Address - Fax:231-887-4574
Practice Address - Street 1:331 4TH ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-2917
Practice Address - Country:US
Practice Address - Phone:231-723-7743
Practice Address - Fax:231-887-4574
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002154225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist