Basic Information
| Provider Information | |||||||||
| NPI: | 1801266309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIVENS | ||||||||
| FirstName: | GUSTAVIA | ||||||||
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| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 431 MACKAY DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094339300 | ||||||||
| FaxNumber: | 9094339300 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 N ARROWHEAD AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924081016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099635355 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.