Provider Demographics
NPI:1407431562
Name:GATEHOUSE PSYCHIATRIC SOLUTIONS LLC
Entity Type:Organization
Organization Name:GATEHOUSE PSYCHIATRIC SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:EXTEROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-963-0674
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-0353
Mailing Address - Country:US
Mailing Address - Phone:608-434-2177
Mailing Address - Fax:
Practice Address - Street 1:201 8TH AVE STE 12
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2112
Practice Address - Country:US
Practice Address - Phone:608-434-2177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty