Provider Demographics
NPI:1730899881
Name:JOHANNESSEN, SAGE STOUT (DPT)
Entity type:Individual
Prefix:
First Name:SAGE
Middle Name:STOUT
Last Name:JOHANNESSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SAGE
Other - Middle Name:AMBER
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1618 CAMBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-1316
Mailing Address - Country:US
Mailing Address - Phone:802-922-0753
Mailing Address - Fax:
Practice Address - Street 1:200 W 12TH ST STE A1-100
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-4771
Practice Address - Country:US
Practice Address - Phone:540-941-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212499225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist