Basic Information
| Provider Information | |||||||||
| NPI: | 1871019711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIVENS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELEANOR | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650B SALEM AVE | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855503715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654013648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733647551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 11/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2017024119 | MO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.