Healthcare Provider Details

I. General information

NPI: 1821929563
Provider Name (Legal Business Name): AVERY BRENNER
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S HAVEN AVE STE 190
ONTARIO CA
91761-2971
US

IV. Provider business mailing address

1500 S HAVEN AVE STE 190
ONTARIO CA
91761-2971
US

V. Phone/Fax

Practice location:
  • Phone: 909-390-1313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number8993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: