Provider Demographics
NPI:1356998421
Name:SOUL SAGE, LLC
Entity type:Organization
Organization Name:SOUL SAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LACOMBE NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-488-8864
Mailing Address - Street 1:9683 W HOMEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5334
Mailing Address - Country:US
Mailing Address - Phone:208-886-0271
Mailing Address - Fax:
Practice Address - Street 1:1617 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5111
Practice Address - Country:US
Practice Address - Phone:208-488-8864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-22
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDAETNAOther60054
ID020200107001043Medicaid