Provider Demographics
NPI:1699758250
Name:LAURA VAIL SAGE INC
Entity type:Organization
Organization Name:LAURA VAIL SAGE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:VAIL
Authorized Official - Last Name:SAGE
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:513-229-7900
Mailing Address - Street 1:5134 CEDAR VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-3717
Mailing Address - Country:US
Mailing Address - Phone:513-229-7900
Mailing Address - Fax:513-229-0202
Practice Address - Street 1:5134 CEDAR VILLAGE DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-3717
Practice Address - Country:US
Practice Address - Phone:513-229-7900
Practice Address - Fax:513-229-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH944032101YA0400X
OHI 00054421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW25652Medicare UPIN