Provider Demographics
NPI:1275393803
Name:GATES, GWEN (NBC-HWC, CPT, CTRS)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:GATES
Suffix:
Gender:F
Credentials:NBC-HWC, CPT, CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:MT
Mailing Address - Zip Code:59922-0637
Mailing Address - Country:US
Mailing Address - Phone:406-407-3833
Mailing Address - Fax:
Practice Address - Street 1:145 TAMARACK WOODS DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:MT
Practice Address - Zip Code:59922-9642
Practice Address - Country:US
Practice Address - Phone:406-407-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225800000X
MTID-A-3438467171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist