Provider Demographics
NPI:1356725808
Name:AVERY CENTRE
Entity type:Organization
Organization Name:AVERY CENTRE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:VENOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MA, MFT-I
Authorized Official - Phone:760-805-4127
Mailing Address - Street 1:5871 PINE AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-6537
Mailing Address - Country:US
Mailing Address - Phone:909-597-2226
Mailing Address - Fax:
Practice Address - Street 1:5871 PINE AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709
Practice Address - Country:US
Practice Address - Phone:909-597-2226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT96181106H00000X
PSY24897251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty