Provider Demographics
NPI:1073151015
Name:HAVEN PSYCHOLOGICAL
Entity Type:Organization
Organization Name:HAVEN PSYCHOLOGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DUPREZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:909-987-1997
Mailing Address - Street 1:8253 WHITE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7671
Mailing Address - Country:US
Mailing Address - Phone:909-987-1997
Mailing Address - Fax:
Practice Address - Street 1:14390 PARK AVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2310
Practice Address - Country:US
Practice Address - Phone:442-327-9311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty