Provider Demographics
NPI:1275355901
Name:SAGE EDUCATIONAL PSYCHOLOGY INC
Entity type:Organization
Organization Name:SAGE EDUCATIONAL PSYCHOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDER VENNET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-852-1630
Mailing Address - Street 1:5247 BEAUMONT WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-2811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 COLLEGE AVE STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5125
Practice Address - Country:US
Practice Address - Phone:707-852-1630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)