Provider Demographics
NPI:1417489733
Name:AVERY, BETTY (LMFT)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:LMFT
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 2566
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92393-2566
Mailing Address - Country:US
Mailing Address - Phone:760-503-5272
Mailing Address - Fax:
Practice Address - Street 1:12469 KOKOMO CIR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-7484
Practice Address - Country:US
Practice Address - Phone:760-503-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83124106H00000X
CA128189106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90-0996079Medicaid