Provider Demographics
NPI:1801554779
Name:SHAW, SAGE BRADLEY (LMLP)
Entity type:Individual
Prefix:
First Name:SAGE
Middle Name:BRADLEY
Last Name:SHAW
Suffix:
Gender:M
Credentials:LMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 RENO RD
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-8754
Mailing Address - Country:US
Mailing Address - Phone:785-214-9338
Mailing Address - Fax:
Practice Address - Street 1:109 W 2ND ST STE A
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-2212
Practice Address - Country:US
Practice Address - Phone:785-242-2991
Practice Address - Fax:785-242-4401
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2025-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMLP03376103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist