Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 10853-120 | WI |
NPI | 1003225335 |
---|---|
Provider Name | Holly Sage |
First Address | Green Bay, WI 54311-5855 |
Second Address | Green Bay, WI 54311-5855 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2014 |
Last Update Date | 12/08/2014 |