Provider Demographics
NPI:1326296856
Name:GATEWAY FOUNDATION, INC.
Entity Type:Organization
Organization Name:GATEWAY FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:ENNIS
Authorized Official - Last Name:MCGEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-445-4833
Mailing Address - Street 1:55 E JACKSON BLVD
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-4466
Mailing Address - Country:US
Mailing Address - Phone:312-663-1130
Mailing Address - Fax:312-663-0504
Practice Address - Street 1:2200 LAKE VICTORIA DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5596
Practice Address - Country:US
Practice Address - Phone:877-505-4673
Practice Address - Fax:217-529-9151
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GATEWAY FOUNDATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-09
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0538-0019-A261QM0801X, 261QR0405X, 3245S0500X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid