Provider Demographics
NPI:1083991525
Name:GOUDGE, SARA (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GOUDGE
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5409 AMBASSADOR BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:MN
Mailing Address - Zip Code:55070-9677
Mailing Address - Country:US
Mailing Address - Phone:612-501-4749
Mailing Address - Fax:
Practice Address - Street 1:23306 CREE ST UNIT 106
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:MN
Practice Address - Zip Code:55070-2307
Practice Address - Country:US
Practice Address - Phone:763-220-0501
Practice Address - Fax:763-312-2056
Is Sole Proprietor?:No
Enumeration Date:2011-11-11
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN385101YP2500X
MNCC00385101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional