Provider Demographics
NPI:1104101310
Name:VAN KONINGSVELD, SARA ROSE
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ROSE
Last Name:VAN KONINGSVELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 642900
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-8314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11835 W OLYMPIC BLVD STE 815E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-5056
Practice Address - Country:US
Practice Address - Phone:323-332-9905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WILPC10289101YM0800X, 101YM0800X
BCDMT1207225600000X
CALPCC8233101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist