Provider Demographics
NPI:1538292388
Name:GATEWAY BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:GATEWAY BEHAVIORAL HEALTH SERVICES
Other - Org Name:GATWAY BHS - LIBERTY GH B
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA CFO
Authorized Official - Phone:912-554-8464
Mailing Address - Street 1:700 COASTAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-1974
Mailing Address - Country:US
Mailing Address - Phone:912-264-0979
Mailing Address - Fax:912-264-5965
Practice Address - Street 1:760 S MAIN ST # B
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4613
Practice Address - Country:US
Practice Address - Phone:912-368-7472
Practice Address - Fax:912-368-7473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000622553ARMedicaid