Provider Demographics
NPI:1447235759
Name:GOBURDHUN, SARA (PHD)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:
Last Name:GOBURDHUN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14555 LEVAN RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5083
Mailing Address - Country:US
Mailing Address - Phone:734-953-0380
Mailing Address - Fax:
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:SUITE 401
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-953-0380
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006142103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680H24703OtherBLUE CROSS BLUE SHIELD
MI6301006142OtherMI STATE LICENSE
MI680H24703OtherBLUE CROSS BLUE SHIELD