Provider Demographics
NPI:1043755580
Name:HERBERT, AVERY
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:HERBERT
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 1:2587 W 1950 N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8491
Mailing Address - Country:US
Mailing Address - Phone:435-690-9279
Mailing Address - Fax:
Practice Address - Street 1:857 E 200 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2317
Practice Address - Country:US
Practice Address - Phone:801-487-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X, 172V00000X, 175T00000X
UT1-21-47656103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist