Healthcare Provider Details

I. General information

NPI: 1043143530
Provider Name (Legal Business Name): MR. AVERY HIMES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 SANTIAGO ST
SAN FRANCISCO CA
94116-1526
US

IV. Provider business mailing address

606 BEAVER ST
SANTA ROSA CA
95404-4228
US

V. Phone/Fax

Practice location:
  • Phone: 415-759-2222
  • Fax:
Mailing address:
  • Phone: 760-954-0573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberRPE20766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: