Provider Demographics
NPI:1275655698
Name:GATES, NATHAN W (MA)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:W
Last Name:GATES
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8 S MAIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2606
Mailing Address - Country:US
Mailing Address - Phone:309-740-2171
Mailing Address - Fax:309-740-2171
Practice Address - Street 1:8 S MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2606
Practice Address - Country:US
Practice Address - Phone:309-740-2171
Practice Address - Fax:309-740-2171
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008351101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional