Basic Information
| Provider Information | |||||||||
| NPI: | 1689861692 | ||||||||
| EntityType: | 2 | ||||||||
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| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1470 W HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937110552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592562000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2007 | ||||||||
| LastUpdateDate: | 10/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | OWHADI | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5592562000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.