Basic Information
Provider Information | |||||||||
NPI: | 1346275880 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GATEWAY HEALTHCARE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1516 ATWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | JOHNSTON | ||||||||
State: | RI | ||||||||
PostalCode: | 029193223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4015531000 | ||||||||
FaxNumber: | 4015531143 | ||||||||
Practice Location | |||||||||
Address1: | 249 ROOSEVELT AVE | ||||||||
Address2: | SUITE 205 | ||||||||
City: | PAWTUCKET | ||||||||
State: | RI | ||||||||
PostalCode: | 028602134 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4017248400 | ||||||||
FaxNumber: | 4013651100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GAUDIOSO | ||||||||
AuthorizedOfficialFirstName: | MARILYN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | LICSW | ||||||||
AuthorizedOfficialTelephone: | 4015531000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LICSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | ISW000702 | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 70579792 | 05 | RI |   | MEDICAID |