1063394567 NPI number — SAGEBROOK BEHAVIORAL HEALTH PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063394567 NPI number — SAGEBROOK BEHAVIORAL HEALTH PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAGEBROOK BEHAVIORAL HEALTH PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063394567
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3360 BLACKFORD PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40509-9070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-457-1904
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 MOORE DR STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40503-2951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-457-1904
Provider Business Practice Location Address Fax Number:
859-214-7634
Provider Enumeration Date:
07/24/2025

Additional Information

Authorized Official

Authorized Official Last Name:
MIREMBO
Authorized Official First Name:
RAY
Authorized Official Middle Name:
I
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
859-457-1904

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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