Healthcare Provider Details

I. General information

NPI: 1417489733
Provider Name (Legal Business Name): BETTY AVERY LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12469 KOKOMO CIR
VICTORVILLE CA
92392-7484
US

IV. Provider business mailing address

PO BOX 2566
VICTORVILLE CA
92393-2566
US

V. Phone/Fax

Practice location:
  • Phone: 760-503-5272
  • Fax:
Mailing address:
  • Phone: 760-503-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number83124
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number128189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: