Provider Demographics
NPI:1598953598
Name:GURGANUS, SARA LEA (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:SARA
Middle Name:LEA
Last Name:GURGANUS
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 EXCELSIOR BLVD STE 717
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2906
Mailing Address - Country:US
Mailing Address - Phone:952-920-0711
Mailing Address - Fax:952-920-0716
Practice Address - Street 1:5115 EXCELSIOR BLVD STE 717
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2906
Practice Address - Country:US
Practice Address - Phone:952-920-0711
Practice Address - Fax:952-920-0716
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4536103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680002051Medicare PIN