Provider Demographics
NPI:1417489733
Name:AVERY, BETTY (MFT)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 N BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-4703
Mailing Address - Country:US
Mailing Address - Phone:909-990-5438
Mailing Address - Fax:
Practice Address - Street 1:689 N BEECHWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-4703
Practice Address - Country:US
Practice Address - Phone:909-990-5438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90-0996079Medicaid