Basic Information
| Provider Information | |||||||||
| NPI: | 1306011838 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1470 W HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937110552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592562000 | ||||||||
| FaxNumber: | 5592563000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1470 W HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937110552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592562000 | ||||||||
| FaxNumber: | 5592563000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 04/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | OWHADI | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 5592562000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.