MEDICARE: MS. SARA JANE GOGERTY MA, LMFT, LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	303027	MN
2	106H00000X	Marriage & Family Therapist	2205	MN

General Provider Information

NPI Number	:	1427349414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SARA JANE GOGERTY MA, LMFT, LADC

Provider Business Mailing Address
First Line	:	8891 BRODERICK BLVD APT 310
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076-5185
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8891 BRODERICK BLVD APT 310
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076-5185
Country	:	US
Telephone Number	:	651-662-2789
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2011
Last Update Date	:	05/20/2014

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