Healthcare Provider Details

I. General information

NPI: 1538612205
Provider Name (Legal Business Name): SARAH MCDONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E COLORADO ST
GLENDALE CA
91205
US

IV. Provider business mailing address

4760 SEPULVEDA BLVD
CULVER CITY CA
90230-4820
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-7257
  • Fax: 818-243-5431
Mailing address:
  • Phone: 310-390-6612
  • Fax: 310-398-5690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number79566
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number79566
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number97598
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: