Provider Demographics
NPI:1710017983
Name:AVERY, JUDITH B (LAC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:B
Last Name:AVERY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 3RD ST
Mailing Address - Street 2:#B
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4101
Mailing Address - Country:US
Mailing Address - Phone:310-392-8390
Mailing Address - Fax:
Practice Address - Street 1:1434 6TH ST
Practice Address - Street 2:#7
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2540
Practice Address - Country:US
Practice Address - Phone:310-395-9160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3208171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist