Provider Demographics
NPI:1639845696
Name:SAGE, KRYSTAL NICOLE (COTA/L, QMHP-C)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:NICOLE
Last Name:SAGE
Suffix:
Gender:F
Credentials:COTA/L, QMHP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 SUGAR GROVE HWY
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:24375-3140
Mailing Address - Country:US
Mailing Address - Phone:276-685-3546
Mailing Address - Fax:
Practice Address - Street 1:927 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4117
Practice Address - Country:US
Practice Address - Phone:276-783-7529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002528224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant