=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619110962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH AVERY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2009
-----------------------------------------------------
Last Update Date | 09/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12304 SANTA MONICA BLVD SUITE 327
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-2551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-722-5367
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1353 S CARMELINA AVE APT 118
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-1940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-722-5367
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT52547
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------