Provider Demographics
NPI:1669716015
Name:BOLTE, SAGE ANNALEISE (PHD, LCSW, OSW-C)
Entity type:Individual
Prefix:DR
First Name:SAGE
Middle Name:ANNALEISE
Last Name:BOLTE
Suffix:
Gender:F
Credentials:PHD, LCSW, OSW-C
Other - Prefix:
Other - First Name:SAGE
Other - Middle Name:ANNALEISE
Other - Last Name:BOLTE-MULLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LCSW, OSW-C
Mailing Address - Street 1:12821 TEWKSBURY DR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2428
Mailing Address - Country:US
Mailing Address - Phone:703-403-2120
Mailing Address - Fax:
Practice Address - Street 1:12821 TEWKSBURY DR
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-2428
Practice Address - Country:US
Practice Address - Phone:703-403-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040061071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical