Provider Demographics
NPI:1770944902
Name:SAGE, WILLIAM NOLAN (LAT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:NOLAN
Last Name:SAGE
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1989
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0240
Mailing Address - Country:US
Mailing Address - Phone:307-857-9456
Mailing Address - Fax:307-460-5791
Practice Address - Street 1:10269 HWY. 789
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-857-9456
Practice Address - Fax:307-460-5791
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-225101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)