Provider Demographics
NPI:1205588506
Name:SAGE MENTAL, LLC
Entity type:Organization
Organization Name:SAGE MENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LILES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:850-502-3090
Mailing Address - Street 1:PO BOX 4418
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32549-4418
Mailing Address - Country:US
Mailing Address - Phone:850-502-3090
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH ST N STE 300
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4399
Practice Address - Country:US
Practice Address - Phone:850-290-7331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty