Basic Information
| Provider Information | |||||||||
| NPI: | 1073800892 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAGE SOCIAL SERVICES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 PEACEFUL LN | ||||||||
| Address2: | |||||||||
| City: | CONVERSE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781091007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102489077 | ||||||||
| FaxNumber: | 2109458489 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PEACEFUL LN | ||||||||
| Address2: | |||||||||
| City: | CONVERSE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781091007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102489077 | ||||||||
| FaxNumber: | 2109458489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2011 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | WRENN-GORDON | ||||||||
| AuthorizedOfficialFirstName: | GLENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2102489077 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | 27796 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | 20064 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.