Provider Demographics
NPI:1598914095
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 1:1080 E PARK ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3812
Practice Address - Country:US
Practice Address - Phone:877-505-4673
Practice Address - Fax:618-549-9540
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GATEWAY FOUNDATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-09
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0538-0003-A261QM0801X, 261QR0405X, 323P00000X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========026Medicaid