Provider Demographics
NPI:1265979397
Name:SAGE TREE PSYCHOLOGY GROUP LLC
Entity type:Organization
Organization Name:SAGE TREE PSYCHOLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:BANE
Authorized Official - Last Name:GVENTER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:248-303-1382
Mailing Address - Street 1:1179 BELLWOOD CT
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6732
Mailing Address - Country:US
Mailing Address - Phone:248-303-1382
Mailing Address - Fax:
Practice Address - Street 1:925 N LAPEER RD
Practice Address - Street 2:STE 151
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6742
Practice Address - Country:US
Practice Address - Phone:248-303-1382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013477103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty