Basic Information
| Provider Information | |||||||||
| NPI: | 1033497524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GATEWOOD | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BA, CATC-I | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAELAK | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8330 RESEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913244619 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8330 RESEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913244619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189961051 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2011 | ||||||||
| LastUpdateDate: | 08/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6038-I | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.