Healthcare Provider Details

I. General information

NPI: 1679287023
Provider Name (Legal Business Name): SARA MOMTAHENI BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 E BROADWAY UNIT 302
GLENDALE CA
91205-1085
US

IV. Provider business mailing address

416 E BROADWAY UNIT 302
GLENDALE CA
91205-1085
US

V. Phone/Fax

Practice location:
  • Phone: 310-436-5224
  • Fax:
Mailing address:
  • Phone: 310-436-5224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12155991
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: