Basic Information
| Provider Information | |||||||||
| NPI: | 1366476707 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY HEALTHCARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 249 ROOSEVELT AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028602134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4013651100 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 HAMLET AVE | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028954410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017661665 | ||||||||
| FaxNumber: | 4017674903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NIXON | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | LCDS | ||||||||
| AuthorizedOfficialTelephone: | 4017661665 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCDS | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | FACILITY CONTRACT | 05 | RI | MEDICAID |