Healthcare Provider Details

I. General information

NPI: 1073151015
Provider Name (Legal Business Name): HAVEN PSYCHOLOGICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14390 PARK AVE
VICTORVILLE CA
92392-2310
US

IV. Provider business mailing address

8253 WHITE OAK AVE
RANCHO CUCAMONGA CA
91730-7671
US

V. Phone/Fax

Practice location:
  • Phone: 442-327-9311
  • Fax:
Mailing address:
  • Phone: 909-987-1997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DR. GERALD ROBERT DUPREZ
Title or Position: OWNER
Credential: PHD
Phone: 909-987-1997