# SPROUTED SAGE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1235703257
- **Authorized official:** DR. SUZI NAGUIB PSY.D. (CLINICAL DIRECTOR)
- **Authorized official phone:** (734) 222-9277

## Contact information

- **Practice address:** 300 N 5TH AVE STE 210, ANN ARBOR, MI 48104-1447
- **Practice address phone:** (734) 222-9277
- **Mailing address:** 300 N 5TH AVE STE 210, ANN ARBOR, MI 48104-1447

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 103TC2200X | Clinical Child & Adolescent Psychologist | — | NULL | Yes |
| 103TC2200X | Clinical Child & Adolescent Psychologist | — | — | Yes |

## Other

- **Enumeration date:** 05/14/2021
- **Last updated:** 05/14/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 12311188 | CAQH ID | — |