Basic Information
Provider Information
NPI: 1003001819
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TAVORA
FirstName: SARA
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: LLMSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 520 SUPERIOR ST
Address2:  
City: PORT HURON
State: MI
PostalCode: 480603838
CountryCode: US
TelephoneNumber: 8109844202
FaxNumber: 8109848896
Practice Location
Address1: 520 SUPERIOR ST
Address2:  
City: PORT HURON
State: MI
PostalCode: 480603838
CountryCode: US
TelephoneNumber: 8109844202
FaxNumber: 8109848896
Other Information
ProviderEnumerationDate: 09/14/2007
LastUpdateDate: 09/14/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X6801089286MIY Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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