Provider Demographics
NPI:1679905137
Name:GITTENS, HORATIUS (MFTI)
Entity Type:Individual
Prefix:
First Name:HORATIUS
Middle Name:
Last Name:GITTENS
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3521
Mailing Address - Country:US
Mailing Address - Phone:909-763-5500
Mailing Address - Fax:
Practice Address - Street 1:1053 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3521
Practice Address - Country:US
Practice Address - Phone:909-763-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00188OtherLEGAL ENTITY NUMBER