Healthcare Provider Details

I. General information

NPI: 1104101310
Provider Name (Legal Business Name): SARA ROSE VAN KONINGSVELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W BROADWAY STE 155
GLENDALE CA
91204-1332
US

IV. Provider business mailing address

PO BOX 642900
LOS ANGELES CA
90064-8314
US

V. Phone/Fax

Practice location:
  • Phone: 818-441-7800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13952768-6004
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC8233
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License NumberBCDMT1207
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC10289
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: