Provider Demographics
NPI:1649645557
Name:SAGE BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:SAGE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, LCPC
Authorized Official - Phone:918-809-7919
Mailing Address - Street 1:RR 1 BOX 184-9
Mailing Address - Street 2:
Mailing Address - City:S COFFEYVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74072-9784
Mailing Address - Country:US
Mailing Address - Phone:918-809-7919
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 184-9
Practice Address - Street 2:
Practice Address - City:S COFFEYVILLE
Practice Address - State:OK
Practice Address - Zip Code:74072-9784
Practice Address - Country:US
Practice Address - Phone:918-809-7919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5538251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200617960AMedicaid