Provider Demographics
NPI:1871019711
Name:GIVENS, MARY ELEANOR (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELEANOR
Last Name:GIVENS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650B SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3409
Mailing Address - Country:US
Mailing Address - Phone:785-550-3715
Mailing Address - Fax:
Practice Address - Street 1:1450 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3648
Practice Address - Country:US
Practice Address - Phone:573-364-7551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017024119103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical