Basic Information
| Provider Information | |||||||||
| NPI: | 1669408340 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY HEALTHCARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 249 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028602134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4013651100 | ||||||||
| Practice Location | |||||||||
| Address1: | 422 POST RD | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028881539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017810033 | ||||||||
| FaxNumber: | 4017810444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FACTEAU | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4017248400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | ISW01153 | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 62-68880 | 01 | RI | UNITED | OTHER |