Healthcare Provider Details

I. General information

NPI: 1003001819
Provider Name (Legal Business Name): SARA M TAVORA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SUPERIOR ST
PORT HURON MI
48060-3838
US

IV. Provider business mailing address

520 SUPERIOR ST
PORT HURON MI
48060-3838
US

V. Phone/Fax

Practice location:
  • Phone: 810-984-4202
  • Fax: 810-984-8896
Mailing address:
  • Phone: 810-984-4202
  • Fax: 810-984-8896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801089286
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: