Provider Demographics
NPI:1801266309
Name:GIVENS, GUSTAVIA JR
Entity type:Individual
Prefix:
First Name:GUSTAVIA
Middle Name:
Last Name:GIVENS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 MACKAY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3222
Mailing Address - Country:US
Mailing Address - Phone:909-433-9300
Mailing Address - Fax:909-433-9300
Practice Address - Street 1:141 N ARROWHEAD AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-1016
Practice Address - Country:US
Practice Address - Phone:909-963-5355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator