Provider Demographics
NPI:1598001828
Name:PHOENIX, SAGE IMOGENE (LMHC (MA #9606))
Entity type:Individual
Prefix:
First Name:SAGE
Middle Name:IMOGENE
Last Name:PHOENIX
Suffix:
Gender:
Credentials:LMHC (MA #9606)
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:ELIZABETH
Other - Last Name:HAMPTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:4238 WASHINGTON ST, STE 313
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131
Mailing Address - Country:US
Mailing Address - Phone:617-453-8512
Mailing Address - Fax:617-992-2580
Practice Address - Street 1:4238 WASHINGTON ST, STE 313
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131
Practice Address - Country:US
Practice Address - Phone:617-453-8512
Practice Address - Fax:617-992-2580
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9606101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid