Provider Demographics
NPI:1700158748
Name:SAGE, HEATHER JEAN (MSE)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:JEAN
Last Name:SAGE
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:JEAN
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:742 STERBENZ DR
Mailing Address - Street 2:AVANTI CENTER
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8327
Mailing Address - Country:US
Mailing Address - Phone:715-386-2128
Mailing Address - Fax:715-386-6119
Practice Address - Street 1:742 STERBENZ DR
Practice Address - Street 2:AVANTI CENTER
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8327
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:715-386-6119
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3634235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3634OtherWISCONSIN LICENSE